PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05 PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT WORKSHEET S CERTIFICATION AND SETTLEMENT SUMMARY PARTS I & II INTERMEDIARY [ ] AUDITED DATE RECEIVED ________ [ ] INITIAL [ ] RE-OPENING USE ONLY: [ ] DESK REVIEWED INTERMEDIARY NO. ________ [ ] FINAL [ ] MCR CODE PART I - CERTIFICATION CHECK __ ELECTRONICALLY FILED COST REPORT DATE: __________ APPLICABLE BOX __ MANUALLY SUBMITTED COST REPORT TIME: __________ MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WHERE OTHERWISE ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT. CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S) I HEREBY CERTIFY THAT I HAVE READ THE ABOVE STATEMENT AND THAT I HAVE EXAMINED THE ACCOMPANYING ELECTRONICALLY FILED OR MANUALLY SUBMITTED COST REPORT AND THE BALANCE SHEET AND STATEMENT OF REVENUE AND EXPENSES PREPARED BY ROCKFORD MEMORIAL HOSPITAL (14-0239) (PROVIDER NAME(S) AND NUMBER(S)) FOR THE COST REPORTING PERIOD BEGINNING 01/01/2008 AND ENDING 12/31/2008, AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS A TRUE, CORRECT AND COMPLETE STATEMENT PREPARED FROM THE BOOKS AND RECORDS OF THE PROVIDER IN ACCORDANCE WITH APPLICABLE INSTRUCTIONS, EXCEPT AS NOTED. I FURTHER CERTIFY THAT I AM FAMILIAR WITH THE LAWS AND REGULATIONS REGARDING THE PROVISION OF HEALTH CARE SERVICES AND THAT THE SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED IN COMPLIANCE WITH SUCH LAWS AND REGULATIONS. (SIGNED) __________________________________________________ OFFICER OR ADMINISTRATOR OF PROVIDER(S) __________________________________________________ TITLE __________________________________________________ DATE PART II - SETTLEMENT SUMMARY TITLE V TITLE XVIII TITLE XIX PART A PART B 1 2 3 4 1 HOSPITAL 233675 -137467 1 2 SUBPROVIDER I 2366 2 3 SWING BED - SNF 3 4 SWING BED - NF 4 5 SKILLED NURSING FACILITY 5 6 NURSING FACILITY 6 7 HOME HEALTH AGENCY 7 8 OUTPATIENT REHABILITATION PROVIDER 8 9 HEALTH CLINIC 9 100 TOTAL 236041 -137467 100 THE ABOVE AMOUNTS REPRESENT 'DUE TO' OR 'DUE FROM' THE APPLICABLE PROGRAM FOR THE ELEMENT OF THE ABOVE COMPLEX INDICATED. ACCORDING TO THE PAPERWORK REDUCTION ACT OF 1995, NO PERSONS ARE REQUIRED TO RESPOND TO A COLLECTION OF INFORMATION UNLESS IT DISPLAYS A VALID OMD CONTROL NUMBER. THE VALID OMB CONTROL NUMBER FOR THIS INFORMATION COLLECTION IS 0938-0050. THE TIME REQUIRED TO COMPLETE THIS INFORMATION COLLECTION IS ESTIMATED 657 HOURS PER RESPONSE, INCLUDING THE TIME TO REVIEW INSTRUCTIONS, SEARCH EXISTING RESOURCES, GATHER THE DATA NEEDED, AND COMPLETE AND REVIEW THE INFORMATION COLLECTION. IF YOU HAVE ANY COMMENTS CONCERNING THE ACCURACY OF THE TIME ESTIMATE(S) OR SUGGESTIONS FOR IMPROVING THIS FORM, PLEASE WRITE TO: HEALTH CARE FINANCING ADMINISTRATION, 7500 SECURITY BOULEVARD, N2-14-26, BALTIMORE, MARYLAND 21244-1850, AND TO THE OFFICE OF THE INFORMATION AND REGULATORY AFFAIRS, OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, D.C. 20503.
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PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX COST REPORT WORKSHEET S CERTIFICATION AND SETTLEMENT SUMMARY PARTS I & II
INTERMEDIARY [ ] AUDITED DATE RECEIVED ________ [ ] INITIAL [ ] RE-OPENING USE ONLY: [ ] DESK REVIEWED INTERMEDIARY NO. ________ [ ] FINAL [ ] MCR CODE
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, CIVILAND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORTWERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WHERE OTHERWISE ILLEGAL, CRIMINAL,CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I HEREBY CERTIFY THAT I HAVE READ THE ABOVE STATEMENT AND THAT I HAVE EXAMINED THE ACCOMPANYING ELECTRONICALLY FILEDOR MANUALLY SUBMITTED COST REPORT AND THE BALANCE SHEET AND STATEMENT OF REVENUE AND EXPENSES PREPARED BY ROCKFORD MEMORIAL HOSPITAL (14-0239) (PROVIDER NAME(S) AND NUMBER(S)) FOR THE COST REPORTING PERIODBEGINNING 01/01/2008 AND ENDING 12/31/2008, AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS A TRUE, CORRECT ANDCOMPLETE STATEMENT PREPARED FROM THE BOOKS AND RECORDS OF THE PROVIDER IN ACCORDANCE WITH APPLICABLE INSTRUCTIONS, EXCEPTAS NOTED. I FURTHER CERTIFY THAT I AM FAMILIAR WITH THE LAWS AND REGULATIONS REGARDING THE PROVISION OF HEALTH CARESERVICES AND THAT THE SERVICES IDENTIFIED IN THIS COST REPORT WERE PROVIDED IN COMPLIANCE WITH SUCH LAWS AND REGULATIONS.
(SIGNED) __________________________________________________ OFFICER OR ADMINISTRATOR OF PROVIDER(S)
__________________________________________________ TITLE
__________________________________________________ DATE
PART II - SETTLEMENT SUMMARY
TITLE V TITLE XVIII TITLE XIX PART A PART B 1 2 3 4 1 HOSPITAL 233675 -137467 1 2 SUBPROVIDER I 2366 2 3 SWING BED - SNF 3 4 SWING BED - NF 4 5 SKILLED NURSING FACILITY 5 6 NURSING FACILITY 6 7 HOME HEALTH AGENCY 7 8 OUTPATIENT REHABILITATION PROVIDER 8 9 HEALTH CLINIC 9 100 TOTAL 236041 -137467 100
THE ABOVE AMOUNTS REPRESENT 'DUE TO' OR 'DUE FROM' THE APPLICABLE PROGRAM FOR THE ELEMENT OF THE ABOVE COMPLEX INDICATED.
ACCORDING TO THE PAPERWORK REDUCTION ACT OF 1995, NO PERSONS ARE REQUIRED TO RESPOND TO A COLLECTION OF INFORMATION UNLESS ITDISPLAYS A VALID OMD CONTROL NUMBER. THE VALID OMB CONTROL NUMBER FOR THIS INFORMATION COLLECTION IS 0938-0050. THE TIME REQUIREDTO COMPLETE THIS INFORMATION COLLECTION IS ESTIMATED 657 HOURS PER RESPONSE, INCLUDING THE TIME TO REVIEW INSTRUCTIONS, SEARCHEXISTING RESOURCES, GATHER THE DATA NEEDED, AND COMPLETE AND REVIEW THE INFORMATION COLLECTION. IF YOU HAVE ANY COMMENTS CONCERNINGTHE ACCURACY OF THE TIME ESTIMATE(S) OR SUGGESTIONS FOR IMPROVING THIS FORM, PLEASE WRITE TO: HEALTH CARE FINANCING ADMINISTRATION,7500 SECURITY BOULEVARD, N2-14-26, BALTIMORE, MARYLAND 21244-1850, AND TO THE OFFICE OF THE INFORMATION AND REGULATORY AFFAIRS,OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, D.C. 20503.
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/23/2009 10:27 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX ADDRESS: 1 STREET: 2400 N ROCKTON AVENUE P.O.BOX: 1 1.01 CITY: ROCKFORD STATE: IL ZIP CODE: 61103 COUNTY: WINNEBAGO 1.01
HOSPITAL AND HOSPITAL-BASED COMPONENT IDENTIFICATION: PAYMENT SYSTEM PROVIDER DATE (P,T,O OR N) COMPONENT COMPONENT NAME NUMBER CERTIFIED V XVIII XIX 0 1 2 3 4 5 6
2 HOSPITAL ROCKFORD MEMORIAL HOSPITAL 14-0239 07/01/1966 N P O 2 3 SUBPROVIDER I RMH PSYCHIATRIC UNIT 14-S239 03/01/1990 N P O 3 4 SWING BEDS - SNF 4 5 SWING BEDS - NF 5 6 HOSPITAL-BASED SNF 6 7 HOSPITAL-BASED NF 7 8 HOSPITAL-BASED OLTC 8 9 HOSPITAL-BASED HHA 9 11 SEPARATELY CERTIFIED ASC 11 12 HOSPITAL-BASED HOSPICE 12 14 HOSP-BASED RHC 14 15 OUTPATIENT REHABILITATION PROVID 15 16 RENAL DIALYSIS RENAL SATELLITE-DIXON 14-3508 10/02/1978 16 16.01 RENAL DIALYSIS II RENAL SATELLITE-DEKALB 14-3513 02/16/1990 16.01 16.02 RENAL DIALYSIS III RENAL SATELLITE-FREEPORT 14-3520 08/17/1994 16.02 16.03 RENAL DIALYSIS IV RENAL SATELLITE-CHURCHVIEW 14-3521 01/04/1996 16.03 16.04 RENAL DIALYSIS V ROCKFORD INCENTER 14-2328 07/01/1966 16.04 16.05 RENAL DIALYSIS VI RENAL SATELLITE-STERLING 14-3525 06/30/1999 16.05
17 COST REPORTING PERIOD (MM/DD/YYYY) FROM: 01/01/2008 TO: 12/31/2008 17 1 2 18 TYPE OF CONTROL 2 18
TYPE OF HOSPITAL/SUBPROVIDER 19 HOSPITAL 1 19 20 SUBPROVIDER I 4 20
OTHER INFORMATION 21 INDICATE IF YOUR HOSPITAL IS EITHER (1) URBAN OR (2) RURAL AT THE END OF THE 21 COST REPORTING PERIOD IN COLUMN 1. IF YOUR HOSPITAL IS GEOGRAPHICALLY CLASSIFIED OR LOCATED IN A RURAL AREA, IS YOUR BED SIZE IN ACCORDANCE WITH CFR 42 412.105 LESS THAN OR EQUAL TO 100 BEDS, ENTER IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO. 21.01 DOES YOUR FACILITY QUALIFY AND IS CURRENTLY RECEIVING PAYMENT FOR YES 21.01 DISPROPORTIONATE SHARE IN ACCORDANCE WITH 42 CFR 412.106? 21.02 HAS YOUR FACILITY RECEIVED GEOGRAPHIC RECLASSIFICATION? ENTER 'Y' FOR YES 21.02 AND 'N' FOR NO. IF YES, REPORT IN COLUMN 2 THE EFFECTIVE DATE. 21.03 ENTER IN COLUMN 1 YOUR GEOGRAPHIC LOCATION EITHER (1) URBAN (2) RURAL. IF YOU ANSWERED 1 N N 21.03 URBAN IN COLUMN 1 INDICATE IF YOU RECEIVED EITHER A WAGE OR STANDARD GEOGRAPHIC RECLASSIFICATION TO A RURAL LOCATION, ENTER IN COLUMN 2 'Y' AND 'N' FOR NO. IF COLUMN 2 IS YES, ENTER IN COLUMN 3 THE EFFECTIVE DATE (mm/dd/yyyy)(SEE INSTRUCTION). DOES YOUR FACILITY CONTAIN 100 OR FEWER BEDS IN ACCORDANCE WITH 42 CFR 412.105? ENTER IN COLUMN 4 'Y' FOR YES AND 'N' FOR NO. ENTER IN COLUMN 5 THE PROVIDERS ACTUAL MSA OR CBSA. 21.04 FOR STANDARD GEOGRAPHIC RECLASSIFICATION (NOT WAGE), WHAT IS YOUR STATUS AT THE BEGINNING 1 21.04 OF THE COST REPORTING PERIOD. ENTER (1) URBAN AND (2) RURAL. 21.05 FOR STANDARD GEOGRAPHIC RECLASSIFICATION (NOT WAGE), WHAT IS YOUR STATUS AT THE END OF THE 1 21.05 COST REPORTING PERIOD. ENTER (1) URBAN AND (2) RURAL. 21.06 DOES THIS HOSPITAL QUALIFY FOR THE THREE-YEAR TRANSITION OF HOLD HARMLESS PAYMENTS FOR A NO 21.06 SMALL RURAL HOSPITAL UNDER THE PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT SERVICES UNDER DRA SECTION 5105? ENTER 'Y' FOR YES AND 'N' FOR NO. 22 ARE YOU CLASSIFIED AS A REFERRAL CENTER? NO 22 23 DOES THIS FACILITY OPERATE A TRANSPLANT CENTER? IF YES, ENTER CERTIFICATION DATE(S) BELOW NO 23 23.01 IF THIS IS A MEDICARE CERTIFIED KIDNEY TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.01 IN COL. 2 AND TERMINATION IN COl. 3. 23.02 IF THIS IS A MEDICARE CERTIFIED HEART TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.02 IN COL. 2 AND TERMINATION IN COL. 3. 23.03 IF THIS IS A MEDICARE CERTIFIED LIVER TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.03 IN COL. 2 AND TERMINATION IN COL. 3. 23.04 IF THIS IS A MEDICARE CERTIFIED LUNG TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE 23.04 IN COL. 2 AND TERMINATION IN COL. 3. 23.05 IF MEDICARE PANCREAS TRANSPLANTS ARE PERFORMED SEE INSTRUCTIONS FOR ENTERING CERTIFICATION 23.05 AND TERMINATION DATE. 23.06 IF THIS IS A MEDICARE CERTIFIED INTESTINAL TRANSPLANT CENTER, ENTER THE CERTIFICATION 23.06 DATE IN COL. 2 AND TERMINATION IN COL. 3. 23.07 IF THIS IS A MEDICARE CERTIFIED ISLET TRANSPLANT CENTER ENTER THE CERTIFICATION DATE 23.07 IN COL. 2 AND TERMINATION IN COL. 3. 24 IF THIS AN ORGAN PROCUREMENT ORGANIZATION (OPO), ENTER THE OPO NUMBER IN COL 2. 24 AND TERMINATION IN COL. 3. 24.01 IF THIS A MEDICARE TRANSPLANT CENTER; ENTER THE CCN (PROVIDER NUMBER) IN COL 2, THE 24.01 CERTIFICATION DATE OR RECERTIFICATION DATE (AFTER DECEMBER 26, 2007) IN COL 3.
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/23/2009 10:27 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 (CONTINUED)
OTHER INFORMATION 25 IS THIS A TEACHING HOSPITAL OR AFFILIATED WITH A TEACHING HOSPITAL AND YOU ARE MAKING NO 25 PAYMENTS FOR I & R? 25.01 IS THIS TEACHING PROGRAM APPROVED IN ACCORDANCE WITH CMS PUB. 15-I, CHAPTER 4? NO 25.01 25.02 IF LINE 25.01 IS YES, WAS MEDICARE PARTICIPATION AND APPROVED TEACHING PROGRAM STATUS NO 25.02 IN EFFECT DURING THE FIRST MONTH OF THE COST REPORTING PERIOD? IF YES, COMPLETE WORKSHEET E-3, PART IV. IF NO, COMPLETE WORKSHEET D-2, PART II. 25.03 AS A TEACHING HOSPITAL, DID YOU ELECT COST REIMBURSEMENT FOR PHYSICIANS' SERVICES AS NO 25.03 DEFINED IN CMS PUB. 15-I, SECTION 2148? IF YES, COMPLETE WORKSHEET D-9. 25.04 ARE YOU CLAIMING COSTS ON LINE 70 OF WORKSHEET A? IF YES, COMPLETE WORKSHEET D-2 NO 25.04 25.05 HAS YOUR FACILITY DIRECT GME FTE CAP (COLUMN 1) OR IME CAP (COLUMN 2) BEEN REDUCED UNDER NO NO 25.05 42 CFR 413.79(c)(3) OR 42 CFR 412.105(f)(1)(iv)(B)? ENTER 'Y' FOR YES AND 'N' FOR NO IN THE APPLICABLE COLUMNS. (SEE INSTRUCTIONS) 25.06 HAS YOUR FACILITY RECEIVED ADDITIONAL DIRECT GME FTE RESIDENT CAP SLOTS OR IME FTE NO NO 25.06 RESIDENT CAP SLOTS UNDER 42 CFR 413.79(c)(4) OR 42 CFR 412.105(f)(1)(iv)(C)? ENTER 'Y' FOR YES AND 'N' FOR NO IN THE APPLICABLE COLUMNS. (SEE INSTRUCTIONS) 26 IF THIS A SOLE COMMUNITY HOSPITAL (SCH), ENTER THE NUMBER OF PERIODS SCH STATUS IN EFFECT. 26 ENTER BEGINNING AND ENDING DATES OF SCH STATUS ON LINE 26.01. SUBSCRIPT LINE 26.01 FOR NUMBER OF PERIODS IN EXCESS OF ONE AND ENTER SUBSEQUENT DATES. 26.01 ENTER THE APPLICABLE SCH DATES: BEGINNING: ENDING: 26.01 26.03 IF THIS A SOLE COMMUNITY HOSPITAL (SCH) FOR ANY PART OF THE COST REPORTING PERIOD, ENTER 26.03 THE NUMBER OF PERIODS WITHIN THIS COST REPORTING PERIOD THAT SCH STATUS WAS IN EFFECT AND THE SCH WAS EITHER PHYSICALLY LOCATED OR CLASSIFIED IN A RURAL AREA. 26.04 IF LINE 26.03 COLUMN 1 IS GREATER THAN ONE ENTER THE EFFECTIVE DATES (SEE INSTRUCTIONS): 26.04 BEGINNING: ENDING: BEGINNING: ENDING: 27 DOES THIS HOSPITAL HAVE AN AGREEMENT UNDER EITHER SECTION 1883 OR SECTION 1913 NO 27 FOR SWING BEDS? IF YES, ENTER THE AGREEMENT DATE (mm/dd/yyyy) IN COLUMN 2. 28 IF THIS FACILITY CONTAINS A HOSPITAL-BASED SNF, ARE ALL PATIENTS UNDER MANAGED CARE 28 OR THERE WAS NO MEDICARE UTILIZATION ENTER 'Y', IF 'N' COMPLETE LINES 28.01 AND 28.02. 28.01 IF HOSPITAL BASED SNF ENTER APPROPRIATE TRANSITION PERIOD 1, 2, 3, OR 100 IN COL 1, ENTER 28.01 IN COLS 2 AND 3 THE WAGE INDEX ADJUSTMENT FACTOR BEFORE AND ON OR AFTER OCTOBER 1st 28.02 ENTER IN COL 1 THE HOSPITAL BASED SNF FACILITY SPECIFIC RATE (FROM YOUR F.I.) 28.02 If YOU HAVE NOT TRANSITIONED TO 100% PPS SNF PAYMENT. IN COL 2 ENTER THE FACILITY CLASSIFICATION URBAN(1) OR RURAL(2). IN COL 3, ENTER THE SNF MSA CODE OR TWO CHARACTER CODE IF A RURAL BASED FACILITY. IN COL 4, ENTER THE SNF CBSA CODE OR TWO CHARACTER CODE IF RURAL BASED FACILITY.
A NOTICE PUBLISHED IN THE 'FEDERAL REGISTER' VOL. 68, NO. 149 AUGUST 4, 2003 PROVIDED FOR AN INCREASE IN THE RUG PAYMENTS BEGINNING 10/01/2003. CONGRESS EXPECTED THIS INCREASE TO BE USED FOR DIRECT PATIENT CARE AND RELATED EXPENSES. ENTER IN COLUMN 1 THE PERCENTAGE OF TOTAL EXPENSES FOR EACH CATEGORY TO TOTAL SNF REVENUE FROM WORKSHEET G-2, PART I, LINE 6, COLUMN 3. INDICATE IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO IF THE SPENDING REFLECTS INCREASES ASSOCIATED WITH DIRECT PATIENT CARE AND RELATED EXPENSES FOR EACH CATEGORY. (SEE INSTRUCTIONS) 28.03 STAFFING 0.00 N 28.03 28.04 RECRUITMENT 0.00 N 28.04 28.05 RETENTION OF EMPLOYEES 0.00 N 28.05 28.06 TRAINING 0.00 N 28.06 28.07 OTHER (SPECIFY) 28.07
29 IS THIS A RURAL HOSPITAL WITH A CERTIFIED SNF WHICH HAS FEWER THAN 50 BEDS IN THE NO 29 AGGREGATE FOR BOTH COMPONENTS, USING THE SWING BED OPTIONAL METHOD OF REIMBURSEMENT? 30 DOES THIS HOSPITAL QUALIFY AS A RURAL PRIMARY CARE HOSPITAL (RPCH)/CRITICAL ACCESS NO 30 HOSPITAL (CAH)? SEE 42 CFR 485.606ff. 30.01 IF SO, IS THIS THE INITIAL 12 MONTH PERIOD FOR THE FACILITY OPERATED AS A RPCH/CAH? 30.01 SEE 42 CFR 413.70. 30.02 IF THIS FACILITY QUALIFIES AS AN RPCH/CAH, HAS IT ELECTED THE ALL-INCLUSIVE METHOD OF 30.02 PAYMENT FOR OUTPATIENT SERVICES? 30.03 IF THIS FACILITY QUALIFIES AS A CAH, IS IT ELIGIBLE FOR COST REIMBURSEMENT FOR AMBULANCE 30.03 SERVICES? IF YES, ENTER IN COLUMN 2 THE DATE OF ELIGIBILITY DETERMINATION (DATE MUST BE ON OR AFTER 12/21/2000) 30.04 IF THIS FACILITY QUALIFIES AS A CAH, IS IT ELIGIBLE FOR COST REIMBURSEMENT FOR I&R TRAINING 30.04 PROGRAMS? ENTER 'Y' FOR YES AND 'N' FOR NO. IF YES, THE GME ELIMINATION WOULD NOT BE ON WORKSHEET B, PART I, COLUMN 26 AND THE PROGRAM WOULD BE COST REIMBURSED. IF YES COMPLETE WORKSHEET D-2, PART II. 31 IS THIS A RURAL HOSPITAL QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? NO 31 SEE 42 CFR 412.113(c). 31.01 IS THIS A RURAL HOSPITAL SUBPROVIDER QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? NO 31.01 SEE 42 CFR 412.113(c).
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/23/2009 10:27 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 (CONTINUED)
MISCELLANEOUS COST REPORTING INFORMATION 32 IS THIS AN ALL-INCLUSIVE RATE PROVIDER? IF YES, ENTER THE METHOD USED (A, B, OR E ONLY) NO 32 IN COLUMN 2. 33 IS THIS A NEW HOSPITAL UNDER 42 CFR 412.300 PPS CAPITAL? ENTER 'Y' FOR YES AND 'N' FOR NO 33 NO IN COLUMN 1. IF YES, FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2002, DO YOU ELECT TO BE REIMBURSED AT 100% FEDERAL CAPITAL PAYMENT. ENTER 'Y' FOR YES AND 'N' FOR NO IN COLUMN 2. 34 IS THIS A NEW HOSPITAL UNDER 42 CFR 413.40(f)(1)(i) TEFRA? NO 34 35 HAVE YOU ESTABLISHED A NEW SUBPROVIDER I (EXLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)? NO 35
V XVIII XIX PROSPECTIVE PAYMENT SYSTEM (PPS) - CAPITAL 1 2 3 36 DO YOU ELECT FULLY PROSPECTIVE PAYMENT METHODOLOGY FOR CAPITAL COSTS? NO YES NO 36 36.01 DOES YOUR FACILITY QUALIFY AND RECEIVE PAYMENT FOR DISPROPORTIONATE SHARE IN ACCORDANCE NO YES NO 36.01 WITH 42CFR412.320? 37 DO YOU ELECT HOLD HARMLESS PAYMENT METHODOLOGY FOR CAPITAL COSTS? NO NO NO 37 37.01 IF YOU ARE A HOLD HARMLESS PROVIDER, ARE YOU FILING ON THE BASIS OF 100% OF FEDERAL RATE? NO NO NO 37.01
TITLE XIX INPATIENT HOSPITAL SERVICES 38 DO YOU HAVE TITLE XIX INPATIENT HOSPITAL SERVICES? YES 38 38.01 IS THIS HOSPITAL REIMBURSED FOR TITLE XIX THROUGH THE COST REPORT EITHER IN FULL OR IN PART? NO 38.01 38.02 DOES THE TITLE XIX PROGRAM REDUCE CAPITAL FOLLOWING THE MEDICARE METHODOLOGY? NO 38.02 38.03 ARE TITLE XIX NF PATIENTS OCCUPYING TITLE XVIII SNF BEDS (DUAL CERTIFICATION)? NO 38.03 38.04 DO YOU OPERATE AN ICF/MR FACILITY FOR PURPOSES OF TITLE XIX? NO 38.04
40 ARE THERE ANY RELATED ORGANIZATION OR HOME OFFICE COSTS AS DEFINED IN CMS PUB. 15-I, YES 40 CHAPTER 10? IF YES, AND THERE ARE HOME OFFICE COSTS, ENTER IN COLUMN 2 THE HOME OFFICE PROVIDER NUMBER. (SEE INSTRUCTIONS) IF THIS FACILITY IS PART OF A CHAIN ORGANIZATION, ENTER THE NAME AND ADDRESS OF THE HOME OFFICE. 40.01 NAME: FI/CONTRACTOR'S NAME: FI/CONTRACTOR'S NUMBER: 40.01 40.02 STREET: P.O.BOX: 40.02 40.03 CITY: STATE: ZIP CODE: 40.03 41 ARE PROVIDER BASED PHYSICIANS' COSTS INCLUDED IN WORKSHEET A? YES 41 42 ARE PHYSICAL THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? NO 42 42.01 ARE OCCUPATIONAL THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? NO 42.01 42.02 ARE SPEECH PATHOLOGY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? NO 42.02 43 ARE RESPIRATORY THERAPY SERVICES PROVIDED BY OUTSIDE PROVIDERS? NO 43 44 IF YOU ARE CLAIMING COST FOR RENAL SERVICES ON WORKSHEET A, ARE THEY INPAT SERVICES ONLY? YES 44 45 HAVE YOU CHANGED YOUR COST ALLOCATION METHODOLOGY FROM THE PREVIOUSLY FILE COST REPORT? NO 45 SEE CMS PUB. 15-II, SECTION 3617. IF YES, ENTER THE APPROVAL DATE (mm/dd/yyyy) IN COLUMN 2. 45.01 WAS THERE A CHANGE IN THE STATISTICAL BASIS? 45.01 45.02 WAS THERE A CHANGE IN THE ORDER OF ALLOCATION? 45.02 45.03 WAS THERE A CHANGE TO THE SIMPLIFIED COST FINDING METHOD? 45.03 46 IF YOU ARE PARTICIPATING IN THE NHCMQ DEMONSTRATION PROJECT (MUST HAVE A HOSPITAL-BASED SNF) 46 DURING THIS COST REPORTING PERIOD, ENTER THE PHASE.
IF THIS FACILITY CONTAINS A PROVIDER THAT QUALIFIES FOR AN EXEMPTION FROM THE APPLICATION OF THE LOWER OF COST OR CHARGES, ENTER A 'Y' FOR EACH COMPONENT AND TYPE OF SERVICE THAT QUALIFIES FOR THE EXEMPTION; ENTER 'N' IF NOT EXEMPT (SEE 42 CFR 413.13).
OUTPATIENT OUTPATIENT OUTPATIENT PART A PART B ASC RADIOLOGY DIAGNOSTIC 1 2 3 4 5 47 HOSPITAL N N N N N 47 48 SUBPROVIDER I N N N N N 48 49 SKILLED NURSING FACILITY N N 49 50 HOME HEALTH AGENCY N N 50
52 DOES THIS HOSPITAL CLAIM EXPENDITURES FOR EXTRAORDINARY CIRCUMSTANCES IN ACCORDANCE WITH NO 52 42 CFR 412.348(e)? 52.01 IF YOU ARE A FULLY PROSPECTIVE OR HOLD HARMLESS PROVIDER ARE YOU ELIGIBLE FOR THE SPECIAL NO 52.01 EXCEPTION PAYMENT PURSUANT TO 42 CFR 412.348(g)? IF YES, COMPLETE L, PART IV. 53 IF THIS IS A MEDICARE DEPENDENT HOSPITAL (MDH), ENTER THE NUMBER OF PERIODS MDH STATUS IN 53 EFFECT. ENTER BEGINNING AND ENDING DATES OF MDH STATUS ON LINE 53.01. SUBSCRIPT LINE 53.01 FOR NUMBER OF PERIODS IN EXCESS OF ONE AND ENTER SUBSEQUENT DATES. 53.01 MDH PERIOD: BEGINNING: ENDING: 53.01 54 LIST AMOUNTS OF MALPRACTICE PREMIUMS AND PAID LOSSES: 54 PREMIUMS: 8438852 PAID LOSSES: AND/OR SELF INSURANCE: 54.01 ARE MALPRACTICE PREMIUMS AND PAID LOSSES REPORTED IN OTHER THAN THE ADMINISTRATIVE AND NO 54.01 GENERAL COST CENTER? IF YES, SUBMIT SUPPORTING SCHEDULE LISTING COST CENTERS AND AMOUNTS CONTAINED THEREIN. 55 DOES YOUR FACILITY QUALIFY FOR ADDITIONAL PROSPECTIVE PAYMENT IN ACCORDANCE WITH NO 55 42 CFR 412.107. ENTER 'Y' FOR YES AND 'N' FOR NO.
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/23/2009 10:27 HOSPITAL AND HEALTH CARE COMPLEX IDENTIFICATION DATA WORKSHEET S-2 (CONTINUED)
DATE Y/N LIMIT Y/N FEES 0 1 2 3 4 56 ARE YOU CLAIMING AMBULANCE COSTS? IF YES, ENTER IN COL 2 THE PAYMENT LIMIT / / NO 0.00 NO 56 PROVIDED FROM YOUR FISCAL INTERMEDIARY. IF THIS IS FIRST YEAR OF OPERATIONS, NO ENTRY IS REQUIRED IN COL 2. IF COL 1 IS 'Y', ENTER 'Y' OR 'N' IN COL 3 WHETHER THIS IS YOUR FIRST YEAR OF OPERATIONS FOR RENDERING AMBULANCE SERVICES. ENTER IN COL 4, IF APPLICABLE, THE FEE SCHEDULES AMOUNTS FOR THE PERIOD BEGINNING ON OR AFTER 4/1/2002. 57 ARE YOU CLAIMING NURSING AND ALLIED HEALTH COSTS? YES 57 58 ARE YOU AN INPATIENT REHABILITATION FACILITY (IRF), OR DO YOU CONTAIN AN IRF SUBPROVIDER? NO 58 ENTER IN COLUMN 1 'Y' FOR YES AND 'N' FOR NO. IF YES HAVE YOU MADE THE ELECTION FOR 100% PPS REIMBURSEMENT? ENTER IN COLUMN 2 'Y' FOR YES AND 'N' FOR NO. THIS OPTION IS ONLY AVAILABLE FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 1/1/2002 AND BEFORE 10/1/2002. 58.01 IF LINE 58 COLUMN 1 IS Y, DOES THE FACILITY HAVE A TEACHING PROGRAM IN THE MOST RECENT 58.01 COST REPORTING PERIOD ENDING ON OR BEFORE NOVEMBER 15, 2004? ENTER IN COLUMN 1 'Y' FOR YES OR 'N' FOR NO. IS THE FACILITY TRAINING RESIDENTS IN A NEW TEACHING PROGRAM IN ACCORDANCE WITH FR VOL 70, NO 156 DATED AUGUST 15, 2005 PAGE 47929? ENTER IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO. IF COLUMN 2 IS Y, ENTER 1, 2, OR 3 RESPECTIVELY IN COLUMN 3 (SEE INSTRUCTIONS) IF THE CURRENT COST REPORTING PERIOD COVERS THE BEGINNING OF THE FOURTH ENTER 4 IN COLUMN 3, OR IF THE SUBSEQUENT ACADEMIC YEARS OF THE NEW TEACHING PROGRAM IN EXISTENCE, ENTER 5. (SEE INSTRUCTIONS) 59 ARE YOU A LONG TERM CARE HOSPITAL (LTCH), OR DO YOU CONTAIN A LTCH SUBPROVIDER? NO 59 ENTER IN COLUMN 1 'Y' FOR YES AND 'N' FOR NO. IF YES HAVE YOU MADE THE ELECTION FOR 100% PPS REIMBURSEMENT? ENTER IN COLUMN 2 'Y' FOR YES AND 'N' FOR NO. (SEE INSTRUCTIONS) 60 ARE YOU AN INPATIENT PSYCHIATRIC FACILITY (IPF), OR DO YOU CONTAIN AN IPF SUBPROVIDER? YES 60 ENTER IN COLUMN 1 'Y' FOR YES AND 'N' FOR NO. IF YES, IS THE IPF OR IPF SUBPROVIDER A NEW FACILITY? ENTER IN COLUMN 2 'Y' FOR YES AND 'N' FOR NO. (SEE INSTRUCTIONS) 60.01 IF LINE 60 COLUMN 1 IS Y, DOES THE FACILITY HAVE A TEACHING PROGRAM IN THE MOST RECENT NO NO 60.01 COST REPORTING PERIOD ENDING ON OR BEFORE NOVEMBER 15, 2004? ENTER 'Y' FOR YES OR 'N' FOR NO. IS THE FACILITY TRAINING RESIDENTS IN A NEW TEACHING PROGRAM IN ACCORDANCE WITH 42 CFR SEC. 412.424(d)(1)(iii)(2)? ENTER IN COLUMN 2 'Y' FOR YES OR 'N' FOR NO. IF COLUMN 2 IS Y, ENTER 1, 2, OR 3 RESPECTIVELY IN COLUMN 3 (SEE INSTRUCTIONS). IF THE CURRENT COST REPORTING PERIOD COVERS THE BEGINNING OF THE FOURTH ENTER 4 IN COLUMN 3, OR IF THE SUBSEQUENT ACADEMIC YEARS OF THE NEW TEACHING PROGRAM IN EXISTENCE, ENTER 5 (SEE INSTR.)MULTICAMPUS 61 DOES THE HOSPITAL HAVE A MULTICAMPUS? ENTER 'Y' FOR YES AND 'N' FOR NO. NO 61 IF LINE 61 IS YES, ENTER THE NAME IN COL. 0, COUNTY IN COL. 1, STATE IN COL. 2, ZIP IN COL. 3, CBSA IN COL. 4 AND FTE/CAMPUS IN COL. 5. FTE/ COUNTY: STATE: ZIP CODE CBSA CAMPUS 1 2 3 4 5
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27
HOSPITAL AND HEALTH CARE COMPLEX STATISTICAL DATA WORKSHEET S-3 PART I
------------I/P DAYS / O/P VISITS / TRIPS----------- CAH LTCH OBS. NO. OF BED DAYS PATIENT TITLE TITLE NONCOVERED TITLE BEDS COMPONENT BEDS AVAILABLE HOURS V XVIII DAYS XIX ADMITTED 1 2 2.01 3 4 4.01 5 5.01
1 HOSPITAL ADULTS & PEDS, EXCL 216 78948 23893 11042 1 SWING BED, OBSERV & HOSPICE DAYS 2 HMO 1745 2 3 HOSPITAL ADULTS & PEDS - 3 SWING BED SNF 4 HOSPITAL ADULTS & PEDS - 4 SWING BED NF 5 TOTAL ADULTS & PEDS 216 78948 23893 11042 5 EXCL OBSERVATION BEDS 6 INTENSIVE CARE UNIT 22 8052 3245 384 6 7 CORONARY CARE UNIT 7 8 BURN INTENSIVE CARE UNIT 8 9 SURGICAL INTENSIVE CARE UNIT 9 9.01 NEONATAL INTENSIVE CARE 40 14640 5916 9.01 9.02 PEDIATRIC INTENSIVE CARE 7 2562 464 9.0210 OTHER SPECIAL CARE (SPECIFY) 10 11 NURSERY 3776 11 12 TOTAL HOSPITAL 285 104202 27138 21582 1213 RPCH VISITS 1314 SUBPROVIDER I 12 4392 711 842 14 15 SKILLED NURSING FACILITY 15 16 NURSING FACILITY 16 17 OTHER LONG TERM CARE 17 18 HOME HEALTH AGENCY 18 20 ASC (DISTINCT PART) 20 21 HOSPICE (DISTINCT PART) 21 23 O/P REHAB PROVIDER 23 24 RHC I 24 25 TOTAL 297 25 26 OBSERVATION BED DAYS 3 3 26 27 AMBULANCE TRIPS 155 27 28 EMPLOYEE DISCOUNT DAYS 28
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 HOSPITAL AND HEALTH CARE COMPLEX STATISTICAL DATA WORKSHEET S-3 PART I (CONTINUED) -----I/P DAYS / O/P VISITS / TRIPS---- ---INTERNS & RES FTES---- --FULL TIME EQUIV-- OBS. OBS. OBS. LESS I&R BEDS NOT TOTAL ALL BEDS BEDS NOT REPL NON- EMPLOYEES NONPAID COMPONENT ADMITTED PATIENTS ADMITTED ADMITTED TOTAL PHYS ANES NET ON PAYROLL WORKERS 5.02 6 6.01 6.02 7 8 9 10 11
1 HOSPITAL ADULTS & PEDS, EXCL. 52152 1 SWING BED, OBSERV & HOSPICE DAYS 2 HMO XIX 2 3 HOSPITAL ADULTS & PEDS - 3 SWING BED SNF 4 HOSPITAL ADULTS & PEDS - 4 SWING BED NF 5 TOTAL ADULTS & PEDS 52152 5 EXCL OBSERVATION BEDS 6 INTENSIVE CARE UNIT 5794 6 7 CORONARY CARE UNIT 7 8 BURN INTENSIVE CARE UNIT 8 9 SURGICAL INTENSIVE CARE UNIT 9 9.01 NEONATAL INTENSIVE CARE 12208 9.01 9.02 PEDIATRIC INTENSIVE CARE 908 9.0210 OTHER SPECIAL CARE (SPECIFY) 10 11 NURSERY 3863 11 12 TOTAL HOSPITAL 74925 1866.49 1213 RPCH VISITS 1314 SUBPROVIDER I 2958 17.18 14 15 SKILLED NURSING FACILITY 15 16 NURSING FACILITY 16 17 OTHER LONG TERM CARE 17 18 HOME HEALTH AGENCY 18 20 ASC (DISTINCT PART) 20 21 HOSPICE (DISTINCT PART) 21 23 O/P REHAB PROVIDER 23 24 RHC I 24 25 TOTAL 1883.67 25 26 OBSERVATION BED DAYS 2998 95 2903 26 27 AMBULANCE TRIPS 27 28 EMPLOYEE DISCOUNT DAYS 28
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 HOSPITAL AND HEALTH CARE COMPLEX STATISTICAL DATA WORKSHEET S-3 PART I (CONTINUED) --------------DISCHARGES------------- TITLE TITLE TITLE TOTAL ALL COMPONENT V XVIII XIX PATIENTS 12 13 14 15
1 HOSPITAL ADULTS & PEDS, EXCL. 5050 4234 13630 1 SWING BED, OBSERV & HOSPICE DAYS 2 HMO XIX 2 3 HOSPITAL ADULTS & PEDS - 3 SWING BED SNF 4 HOSPITAL ADULTS & PEDS - 4 SWING BED NF 5 TOTAL ADULTS & PEDS 5 EXCL OBSERVATION BEDS 6 INTENSIVE CARE UNIT 6 7 CORONARY CARE UNIT 7 8 BURN INTENSIVE CARE UNIT 8 9 SURGICAL INTENSIVE CARE UNIT 9 9.01 NEONATAL INTENSIVE CARE 9.01 9.02 PEDIATRIC INTENSIVE CARE 9.0210 OTHER SPECIAL CARE (SPECIFY) 10 11 NURSERY 11 12 TOTAL HOSPITAL 5050 4234 13630 1213 RPCH VISITS 1314 SUBPROVIDER I 139 182 676 14 15 SKILLED NURSING FACILITY 15 16 NURSING FACILITY 16 17 OTHER LONG TERM CARE 17 18 HOME HEALTH AGENCY 18 20 ASC (DISTINCT PART) 20 21 HOSPICE (DISTINCT PART) 21 23 O/P REHAB PROVIDER 23 24 RHC I 24 25 TOTAL 25 26 OBSERVATION BED DAYS 26 27 AMBULANCE TRIPS 27 28 EMPLOYEE DISCOUNT DAYS 28
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 HOSPITAL WAGE INDEX INFORMATION RECLASS. ADJUSTED PAID HOURS AVERAGE WORKSHEET S-3 OF SALARIES SALARIES RELATED HOURLY WAGE PART IIPART II - WAGE DATA AMOUNT FROM WKST. (COL.1 + TO SALARY (COL.3 / DATA REPORTED A-6 COL.2) IN COL.3 COL.4) SOURCE SALARIES 1 2 3 4 5 6 1 TOTAL SALARIES 104123009 104123009 3939558.99 26.43 1 2 NON-PHYSICIAN ANESTHETIST PART A 2 3 NON-PHYSICIAN ANESTHETIST PART B 3 4 PHYSICIAN - PART A 4 4.01 TEACHING PHYSICIAN SALARIES 4.01 5 PHYSICIAN - PART B 5 5.01 NON-PHYSICIAN - PART B 5.01 6 INTERNS & RESIDENTS (IN APPR PGM) 6 6.01 CONTRACT SERVICES, I&R 6.01 7 HOME OFFICE PERSONNEL 7 8 SNF 8 8.01 EXCLUDED AREA SALARIES 2912186 120161 3032347 101292.70 29.94 PAYROLL 8.01 OTHER WAGES & RELATED COSTS 9 CONTRACT LABOR 3113066 3113066 48033.04 64.81 INVOICES 9 9.01 PHARMACY SERVICES UNDER CONTRACT 9.01 9.02 LABORATORY SERVICES UNDER CONTRACT 9.02 9.03 MANAGEMENT AND ADMINISTRATIVE SERVICES' 9.0310 CONTRACT LABOR: PHYSICIAN PART A 1252950 1252950 10840.00 115.59 GL AND CONTRACT 1010.01 TEACHING PHYSICIAN UNDER CONTRACT 10.0111 HOME OFFICE SALARIES & WAGE REL COSTS 3759162 3759162 29834.07 126.00 HO CR 1112 HOME OFFICE: PHYSICIAN PART A 1212.01 TEACHING PHYSICIAN SALARIES 12.01 WAGE-RELATED COSTS13 WAGE RELATED COSTS (CORE) 31917470 -820652 31096818 CMS 339 1314 WAGE RELATED COSTS (OTHER) CMS 339 1415 EXCLUDED AREAS 820652 820652 CMS 339 1516 NON-PHYSICIAN ANESTHETIST PART A CMS 339 1617 NON-PHYSICIAN ANESTHETIST PART B CMS 339 1718 PHYSICIAN PART A CMS 339 1818.01 PART A TEACHING PHYSICIANS CMS 339 18.0119 PHYSICIAN PART B CMS 339 1919.01 WAGE RELATED COSTS (RHC/FQHC) 19.0120 INTERNS & RESIDENTS (IN APPR PGM) CMS 339 20 OVERHEAD COSTS - DIRECT SALARIES21 EMPLOYEE BENEFITS 2526018 2526018 130228.13 19.40 2122 ADMINISTRATIVE & GENERAL 12125624 -54516 12071108 441598.75 27.34 2222.01 ADMINISTRATIVE & GENERAL UNDER CONTACT 2674109 2674109 11037.28 242.28 22.0123 MAINTENANCE & REPAIRS 2324 OPERATION OF PLANT 2733680 2733680 123868.48 22.07 2425 LAUNDRY & LINEN SERVICE 108491 108491 10113.12 10.73 2526 HOUSEKEEPING 1965754 1965754 163317.94 12.04 2626.01 HOUSEKEEPING UNDER CONTRACT 34232 34232 2691.90 12.72 26.0127 DIETARY 2191896 -1066082 1125814 130238.37 8.64 2727.01 DIETARY UNDER CONTRACT 404852 404852 7680.00 52.72 27.0128 CAFETERIA 1066082 1066082 43921.14 24.27 2829 MAINTENANCE OF PERSONNEL 2930 NURSING ADMINISTRATION 2419971 2419971 80411.38 30.09 3031 CENTRAL SERVICES AND SUPPLY 1264636 1264636 82733.83 15.29 3132 PHARMACY 3295416 3295416 87539.54 37.64 3233 MEDICAL RECORDS & MEDICAL RECORDS LIBR 2094022 2094022 109338.31 19.15 3334 SOCIAL SERVICE 244172 244172 9162.73 26.65 3435 OTHER GENERAL SERVICE 35
HOSPITAL WAGE INDEX INFORMATION WORKSHEET S-3 PART III
RECLASS. ADJUSTED PAID HOURS AVERAGE OF SALARIES SALARIES RELATED HOURLY WAGE AMOUNT FROM WKST. (COL.1 + TO SALARY (COL.3 / PART III - HOSPITAL WAGE INDEX SUMMARY REPORTED A-6 COL.2) IN COL.3 COL.4) 1 2 3 4 5
1 NET SALARIES 107236202 107236202 3960968.17 27.07 1 2 EXCLUDED AREA SALARIES 2912186 120161 3032347 101292.70 29.94 2 3 SUBTOTAL SALARIES (LINE 1 MINUS LINE 2) 104324016 -120161 104203855 3859675.47 27.00 3 4 SUBTOTAL OTHER WAGES & REL COSTS 8125178 8125178 88707.11 91.60 4 5 SUBTOTAL WAGE-RELATED COSTS 31917470 -820652 31096818 29.84% 5 6 TOTAL (SUM OF LINES 3 THRU 5) 144366664 -940813 143425851 3948382.58 36.33 6 7 NET SALARIES 7 8 EXCLUDED AREA SALARIES 8 9 SUBTOTAL SALARIES (LINE 7 MINUS LINE 8) 910 SUBTOTAL OTHER WAGES & REL COSTS 1011 SUBTOTAL WAGE-RELATED COSTS 1112 TOTAL (SUM OF LINES 9 THRU 11) 1213 TOTAL OVERHEAD COSTS 34082873 -54516 34028357 1433880.90 23.73 13
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 HOSPITAL RENAL DIALYSIS DEPARTMENT STATISTICAL DATA COMPONENT NO: 14-3508 WORKSHEET S-5
RENAL DIALYSIS STATISTICS
---- OUTPATIENT --- ---- TRAINING ---- ------ HOME ------ HEMO- CAPD HEMO- CAPD REGULAR HIGH FLUX DIALYSIS CCPD DIALYSIS CCPD 1 2 3 4 5 6
1 NUMBER OF PATIENTS IN PROGRAM AT END OF COST 1 REPORTING PERIOD 2 NUMBER OF TIMES PER WEEK PATIENT RECEIVES DIALYSIS 2 3 AVERAGE PATIENT DIALYSIS TIME INCLUDING SETUP 3 4 CAPD EXCHANGES PER DAY 4 5 NUMBER OF DAYS IN YEAR DIALYSIS FURNISHED 5 6 NUMBER OF STATIONS 6 7 TREATMENT CAPACITY PER DAY PER STATION 7 8 UTILIZATION 8 9 AVERAGE TIMES DIALYZERS RE-USED 910 PERCENTAGE OF PATIENTS RE-USING DIALYZERS 10
TRANSPLANT INFORMATION11 NUMBER OF PATIENTS ON TRANSPLANT LIST 1112 NUMBER OF PATIENTS TRANSPLANTED DURING THE COST REPORTING PERIOD 12
EPOIETIN13 NET COSTS OF EPOIETIN FURNISHED TO ALL MAINTENANCE DIALYSIS PATIENTS BY THE PROVIDER 1313.01 EPOIETIN AMOUNT FROM WORKSHEET A FOR HOME DIALYSIS PROGRAM 13.0114 NUMBER OF EPO UNITS FURNISHED RELATING TO THE RENAL DIALYSIS DEPARTMENT 1414.01 NUMBER OF EPO UNITS FURNISHED RELATING TO THE HOME DIALYSIS DEPARTMENT 14.01
PHYSICIAN PAYMENT METHOD (ENTER 'X' IF METHOD(S) IS APPLICABLE)15 MCP X INITIAL METHOD 15
ARANESP16 NET COSTS OF ARANESP FURNISHED TO ALL MAINTENANCE DIALYSIS PATIENTS BY THE PROVIDER 1617 ARANESP AMOUNT FROM WORKSHEET A FOR HOME DIALYSIS PROGRAM 1718 NUMBER OF ARANESP UNITS FURNISHED RELATING TO THE RENAL DIALYSIS DEPARTMENT 1819 NUMBER OF ARANESP UNITS FURNISHED RELATING TO THE HOME DIALYSIS DEPARTMENT 19
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (4/2005) 05/23/2009 10:27 NHCMQ DEMONSTRATION STATISTICAL DATA WORKSHEET S-7 STATISTICAL DATA
M3PI SERVICES SERVICES GROUP REVENUE PRIOR TO JANUARY 1 ON OR AFTER JANUARY 1 TOTAL CODE RATE DAYS RATE DAYS 1 2 3 3.01 4 4.01 5
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (6/2003) 05/23/2009 10:27 HOSPITAL UNCOMPENSATED CARE DATA WORKSHEET S-10
UNCOMPENSATED CARE INFORMATION
1 DO YOU HAVE A WRITTEN CHARITY CARE POLICY? 1 2 ARE PATIENTS WRITE-OFFS IDENTIFIED AS CHARITY? IF YES ANSWER LINES 2.01 THRU 2.04 2 2.01 IS IT AT THE TIME OF ADMISSION? 2.01 2.02 IS IT AT THE TIME OF FIRST BILLING? 2.02 2.03 IS IT AFTER SOME COLLECTION EFFORT HAS BEEN MADE? 2.03 2.04 OTHER METHODS OF WRITE-OFFS (SPECIFY) 2.04 3 ARE CHARITY WRITE-OFFS MADE FOR PARTIAL BILLS? 3 4 ARE CHARITY DETERMINATION BASED UPON ADMINISTRATIVE JUDGMENT WITHOUT FINANCIAL DATA? 4 5 ARE CHARITY DETERMINATION BASED UPON INCOME DATA ONLY? 5 6 ARE CHARITY DETERMINATION BASED UPON NET WORTH DATA? 6 7 ARE CHARITY DETERMINATION BASED UPON INCOME AND NET WORTH DATA? 7 8 DOES YOUR ACCOUNTING SYSTEM SEPARATELY IDENTIFY BAD DEBT AND CHARITY CARE? IF YES ANSWER 8.01 8 8.01 DO YOU SEPARATELY ACCOUNT FOR INPATIENT AND OUTPATIENT SERVICES? 8.01 9 IS DISCERNING CHARITY FROM BAD DEBT A HIGH PRIORITY IN YOUR INSTITUTION? IF NO ANSWER 9.01 THRU 9.04 9 9.01 IS IT BECAUSE THERE IS NOT ENOUGH STAFF TO DETERMINE ELIGIBILITY? 9.01 9.02 IS IT BECAUSE THERE IS NO FINANCIAL INCENTIVE TO SEPARATE CHARITY FROM BAD DEBT? 9.02 9.03 IS IT BECAUSE THERE IS NO CLEAR DIRECTIVE POLICY ON CHARITY DETERMINATION? 9.03 9.04 IS IT BECAUSE YOUR INSTITUTION DOES NOT DEEM THE DISTINCTION IMPORTANT? 9.0410 IF CHARITY DETERMINATIONS ARE MADE BASED UPON INCOME DATA, WHAT IS THE MAXIMUM INCOME THAT CAN BE EARNED 10 BY PATIENTS (SINGLE WITHOUT DEPENDENT) AND STILL DETERMINED TO BE A CHARITY WRITE-OFF?11 IF CHARITY DETERMINATIONS ARE MADE BASED UPON INCOME DATA, IS THE INCOME DIRECTLY TIED TO FEDERAL POVERTY 11 LEVEL? IF YES ANSWER LINES 11 THRU 11.0411.01 IS THE PERCENTAGE LEVEL USED LESS THAN 100% OF THE FEDERAL POVERTY LEVEL? 11.0111.02 IS THE PERCENTAGE LEVEL USED BETWEEN 100% AND 150% OF THE FEDERAL POVERTY LEVEL? 11.0211.03 IS THE PERCENTAGE LEVEL USED BETWEEN 150% AND 200% OF THE FEDERAL POVERTY LEVEL? 11.0311.04 IS THE PERCENTAGE LEVEL USED GREATER THAN 200% OF THE FEDERAL POVERTY LEVEL? 11.0412 ARE PARTIAL WRITE-OFFS GIVEN TO HIGHER INCOME PATIENTS ON A GRADUAL SCALE? 12 13 IS THERE CHARITY CONSIDERATION GIVEN TO HIGH NET WORTH PATIENTS WHO HAVE CATASTROPHIC OR OTHER 13 EXTRAORDINARY MEDICAL EXPENSES?14 IS YOUR HOSPITAL STATE AND LOCAL GOVERNMENT OWNED? IF YES ANSWER LINE 14.01 14 14.01 DO YOU RECEIVE DIRECT FINANCIAL SUPPORT FROM THE GOVERNMENT ENTITY FOR THE PURPOSE OF PROVIDING 14.01 UNCOMPENSATED CARE?14.02 WHAT PERCENTAGE OF THE AMOUNT ON LINE 14.01 IS FROM GOVERNMENT FUNDING? 14.0215 DO YOU RECEIVE RESTRICTED GRANTS FOR RENDERING CARE TO CHARITY PATIENTS? 15 16 ARE OTHER NON-RESTRICTED GRANTS USED TO SUBSIDIZE CHARITY CARE? 16 17 REVENUE RELATED TO UNCOMPENSATED CARE 17 17.01 GROSS MEDICAID REVENUES 33687982 17.0118 REVENUES FROM STATE AND LOCAL INDIGENT CARE PROGRAMS 18 19 REVENUE RELATED TO SCHIP (SEE INSTRUCTIONS) 19 20 RESTRICTED GRANTS 20 21 NON-RESTRICTED GRANTS 21 22 TOTAL GROSS UNCOMPENSATED CARE REVENUES 33687982 22 23 TOTAL CHARGES FOR PATIENTS COVERED BY STATE AND LOCAL INDIGENT CARE PROGRAMS 23 24 COST TO CHARGE RATIO 0.352262 24 25 TOTAL STATE AND LOCAL INDIGENT CARE PROGRAM COST 25 26 TOTAL SCHIP CHARGES FROM YOUR RECORDS 26 27 TOTAL SCHIP COST 27 28 TOTAL GROSS MEDICAID CHARGES FROM YOUR RECORDS 134593876 28 29 TOTAL GROSS MEDICAID COST 47412308 29 30 OTHER UNCOMPENSATED CARE CHARGES (FROM YOUR RECORDS) 32934327 30 31 UNCOMPENSATED CARE COST 11601512 31 32 TOTAL UNCOMPENSATED CARE COST TO THE HOSPITAL 47412308 32
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES WORKSHEET A
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES WORKSHEET A
RECLASS. NET EXP RECLASSI- TRIAL ADJUST- FOR COST CENTER SALARIES OTHER TOTAL FICATIONS BALANCE MENTS ALLOCATION 1 2 3 4 5 6 7 69.30 6930 OUTPATIENT OCCUPATIONAL THERAPY 69.30 69.40 6940 OUTPATIENT SPEECH PATHOLOGY 69.40 71 7100 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 8510 PANCREAS ACQUISITION 85.01 85.02 8520 INTESTINAL ACQUISITION 85.02 85.03 8530 ISLET CELL ACQUISITION 85.03 95 SUBTOTALS 103660874 163090162 266751036 31409 266782445 -21369941 245412504 95 NONREIMBURSABLE COST CENTERS 98 9800 PHYSICIANS' PRIVATE OFFICES 1247756 1247756 1247756 1247756 98 100 7950 GUEST CENTER 59948 302399 362347 -14634 347713 -128315 219398 100 100.01 7954 OTHER NONREIMBURSEABLE COST CEN 100.01100.02 7951 COMMUNITY SERVICES 309141 1158085 1467226 -6986 1460240 1460240 100.02100.04 7952 AUXILIARY 93046 466074 559120 -9789 549331 549331 100.04100.07 7953 ROCKFORD HEALTH SYSTEM 100.07100.08 7955 DIALYSIS RENTED SPACE 100.08101 TOTAL 104123009 166264476 270387485 270387485 -21498256 248889229 101
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 RECLASSIFICATIONS WORKSHEET A-6 PAGE 1
EXPLANATION OF RECLASSIFICATION ENTRY CODE ------------------------------ INCREASE ------------------------------ COST CENTER LINE # SALARY OTHER 1 2 3 4 5
1 DRUGS CHARGED TO PATIENTS A DRUGS CHARGED TO PATIENTS 56 9653648 1 2 2 3 3 4 RECLASS RADIOLOGY ADMIN B MRI 59.01 30602 62074 4 5 B RADIOLOGY-THERAPEUTIC 42 40552 82257 5 6 B RADIOISOTOPE 43 11371 23066 6 7 B CT SCAN 59.02 32828 66589 7 8 B PARAMDICAL ED PROGRAM XRAY 24 65645 133157 8 9 910 1011 OP CARDIAC PROCEDURES C CARDIAC CATHETERIZATION 59.03 273223 130452 1112 1213 1314 EMT MEDICAL DIRECTOR D PARAMED EDUC EMT PROGRAM 24.02 30000 1415 1516 1617 SHARED DIETARY EXPENSES E CAFETERIA 12 1066082 2090583 1718 1819 1920 RECLASS MED SUPPLIES CHGD PAT F MEDICAL SUPPLIES CHARGED TO P 55 14279393 2021 F 2122 F 2223 2324 2425 NURSERY COSTS G NURSERY 33 687128 291512 2526 G NURSERY 33 460345 208619 2627 2728 2829 DEPARTMENTAL DEPRECIATION H NEW CAP REL COSTS-BLDG & FIXT 3 2718324 2930 H NEW CAP REL COSTS-MVBLE EQUIP 4 12398592 3031 H 3132 H 3233 H 3334 H 3435 H 3536 SUBTOTAL 2667776 42168266 36
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 RECLASSIFICATIONS WORKSHEET A-6 PAGE 1
EXPLANATION OF CODE ------------------------------ DECREASE ------------------------------ WKST A-7 RECLASSIFICATION ENTRY COST CENTER LINE # SALARY OTHER REF. 1 6 7 8 9 10
1 DRUGS CHARGED TO PATIENTS A PHARMACY 16 9653648 1 2 2 3 3 4 RECLASS RADIOLOGY ADMIN B RADIOLOGY-DIAGNOSTIC 41 180998 367143 4 5 B 5 6 B 6 7 B 7 8 B 8 9 910 1011 OP CARDIAC PROCEDURES C ADULTS & PEDIATRICS 25 273223 130452 1112 1213 1314 EMT MEDICAL DIRECTOR D ADMINISTRATIVE & GENERAL 6 30000 1415 1516 1617 SHARED DIETARY EXPENSES E DIETARY 11 1066082 2090583 1718 1819 1920 RECLASS MED SUPPLIES CHGD PAT F CENTRAL SERVICES & SUPPLY 15 2599841 2021 F OPERATING ROOM 37 11185836 2122 F RESPIRATORY THERAPY 49 493716 2223 2324 2425 NURSERY COSTS G ADULTS & PEDIATRICS 25 687128 291512 2526 G NEONATAL INTENSIVE CARE 29.01 460345 208619 2627 2728 2829 DEPARTMENTAL DEPRECIATION H EMPLOYEE BENEFITS 5 40073 9 2930 H ADMINISTRATIVE & GENERAL 6 4729568 9 3031 H OPERATION OF PLANT 8 486949 3132 H LAUNDRY & LINEN SERVICE 9 7026 3233 H HOUSEKEEPING 10 24429 3334 H DIETARY 11 111045 3435 H NURSING ADMINISTRATION 14 33420 3536 SUBTOTAL 2667776 32483860 36
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 RECLASSIFICATIONS WORKSHEET A-6 PAGE 2
EXPLANATION OF RECLASSIFICATION ENTRY CODE ------------------------------ INCREASE ------------------------------ COST CENTER LINE # SALARY OTHER 1 2 3 4 5
1 H 1 2 H 2 3 H 3 4 H 4 5 H 5 6 H 6 7 H 7 8 H 8 9 H 910 H 1011 H 1112 H 1213 H 1314 H 1415 H 1516 H 1617 H 1718 H 1819 H 1920 H 2021 H 2122 H 2223 H 2324 H 2425 H 2526 H 2627 H 2728 H 2829 H 2930 H 3031 H 3132 H 3233 H 3334 H 3435 H 3536 SUBTOTAL 2667776 42168266 36
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 RECLASSIFICATIONS WORKSHEET A-6 PAGE 2
EXPLANATION OF CODE ------------------------------ DECREASE ------------------------------ WKST A-7 RECLASSIFICATION ENTRY COST CENTER LINE # SALARY OTHER REF. 1 6 7 8 9 10
1 H CENTRAL SERVICES & SUPPLY 15 246935 1 2 H PHARMACY 16 971412 2 3 H MEDICAL RECORDS & LIBRARY 17 66529 3 4 H PARAMDICAL ED PROGRAM XRAY 24 90 4 5 H PARAMED EDUC EMT PROGRAM 24.02 17560 5 6 H ADULTS & PEDIATRICS 25 1265095 6 7 H INTENSIVE CARE UNIT 26 154366 7 8 H NEONATAL INTENSIVE CARE 29.01 216910 8 9 H PEDIATRIC INTENSIVE CARE 29.02 67366 910 H SUBPROVIDER I 31 42874 1011 H OPERATING ROOM 37 1167696 1112 H RECOVERY ROOM 38 24437 1213 H DELIVERY ROOM & LABOR ROOM 39 269014 1314 H ANESTHESIOLOGY 40 74528 1415 H RADIOLOGY-DIAGNOSTIC 41 1443149 1516 H RADIOLOGY-THERAPEUTIC 42 284621 1617 H RADIOISOTOPE 43 37459 1718 H LABORATORY 44 702165 1819 H BLOOD STORING, PROCESSING & T 47 10254 1920 H RESPIRATORY THERAPY 49 266826 2021 H PHYSICAL THERAPY 50 4714 2122 H ELECTROCARDIOLOGY 53 106946 2223 H ELECTROENCEPHALOGRAPHY 54 27395 2324 H RENAL DIALYSIS 57 33258 2425 H GI LAB 59 228345 2526 H MRI 59.01 378672 2627 H CT SCAN 59.02 274574 2728 H CARDIAC CATHETERIZATION 59.03 568594 2829 H WOMEN'S HEALTH ADVANTAGE 59.05 1954 2930 H SPECIAL SURGICAL SERVICES 59.08 7279 3031 H GENETIC SERVICES 59.10 28122 3132 H PAIN CENTER 60.01 98901 3233 H ANTENATAL TEST CENTER 60.02 103424 3334 H CHILD PSYCHIATRIC CLINIC 60.03 3477 3435 H EMERGENCY 61 433569 3536 SUBTOTAL 2667776 42112370 36
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 RECLASSIFICATIONS WORKSHEET A-6 PAGE 3
EXPLANATION OF RECLASSIFICATION ENTRY CODE ------------------------------ INCREASE ------------------------------ COST CENTER LINE # SALARY OTHER 1 2 3 4 5
1 H 1 2 H 2 3 H 3 4 4 5 5 6 INSURANCE RECLASS I EMPLOYEE BENEFITS 5 97887 6 7 I NEW CAP REL COSTS-BLDG & FIXT 3 239458 7 8 I 8 9 I 910 1011 PASTORAL EDUCATION PROGRAM J PASTORAL EDUCATION PROGRAM 24.01 54516 13278 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 3435 3536 TOTAL RECLASSIFICATIONS 2722292 42518889 36
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 RECLASSIFICATIONS WORKSHEET A-6 PAGE 3
EXPLANATION OF CODE ------------------------------ DECREASE ------------------------------ WKST A-7 RECLASSIFICATION ENTRY COST CENTER LINE # SALARY OTHER REF. 1 6 7 8 9 10
1 H AMBULANCE SERVICES 65 31473 1 2 H GUEST CENTER 100 14634 2 3 H AUXILIARY 100.04 9789 3 4 4 5 5 6 INSURANCE RECLASS I ADMINISTRATIVE & GENERAL 6 327926 6 7 I LABORATORY 44 2433 12 7 8 I COMMUNITY SERVICES 100.02 6986 8 9 I 910 1011 PASTORAL EDUCATION PROGRAM J ADMINISTRATIVE & GENERAL 6 54516 13278 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 3435 3536 TOTAL RECLASSIFICATIONS 2722292 42518889 36
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27
ANALYSIS OF CHANGES DURING COST REPORTING WORKSHEET A-7 PERIOD IN CAPITAL ASSET BALANCES OF HOSPITAL PARTS I & II AND HOSPITAL HEALTH CARE COMPLEX CERTIFIED TO PARTICIPATE IN HEALTH CARE PROGRAMS
PART I - ANALYSIS OF CHANGES IN OLD CAPITAL ASSET BALANCES
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 PART III - RECONCILIATION OF CAPITAL COST CENTERS WORKSHEET A-7 PARTS III & IV
---------- COMPUTATION OF RATIOS ---------- ------ ALLOCATION OF OTHER CAPITAL ------- GROSS OTHER GROSS CAPITALIZED ASSETS CAPITAL- DESCRIPTION ASSETS LEASES FOR RATIO INSURANCE TAXES RELATED TOTAL RATIO COSTS 1 2 3 4 5 6 7 8
1 OLD CAP REL COSTS-BLDG & FIXT .000000 1 2 OLD CAP REL COSTS-MVBLE EQUIP .000000 2 3 NEW CAP REL COSTS-BLDG & FIXT 137294641 137294641 .518619 3 4 NEW CAP REL COSTS-MVBLE EQUIP 127436424 127436424 .481381 4 5 TOTAL 264731065 264731065 1.000000 5
---------------------- SUMMARY OF OLD AND NEW CAPITAL ---------------------- OTHER DEPREC- CAPITAL- DESCRIPTION IATION LEASE INTEREST INSURANCE TAXES RELATED TOTAL COSTS 9 10 11 12 13 14 15
1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 2658832 239458 2898290 3 4 NEW CAP REL COSTS-MVBLE EQUIP 12390945 12390945 4 5 TOTAL 15049777 239458 15289235 5
PART IV - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 THRU 4 ---------------------- SUMMARY OF OLD AND NEW CAPITAL ---------------------- OTHER DEPREC- CAPITAL- DESCRIPTION IATION LEASE INTEREST INSURANCE TAXES RELATED TOTAL COSTS 9 10 11 12 13 14 15
1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 TOTAL 5
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 ADJUSTMENTS TO EXPENSES WORKSHEET A-8 EXPENSE CLASSIFICATION ON WORKSHEET A TO/ FROM WHICH THE AMOUNT IS TO BE ADJUSTED WKST A-7 DESCRIPTION BASIS AMOUNT COST CENTER LINE NO. REF 1 2 3 4 5
1 INVESTMENT INCOME-OLD BLDGS & FIXTURES OLD CAP REL COSTS-BLDG & FIXT 1 1 2 INVESTMENT INCOME-OLD MOVABLE EQUIPMENT OLD CAP REL COSTS-MVBLE EQUIP 2 2 3 INVESTMENT INCOME-NEW BLDGS & FIXTURES NEW CAP REL COSTS-BLDG & FIXT 3 3 4 INVESTMENT INCOME-NEW MOVABLE EQUIPMENT NEW CAP REL COSTS-MVBLE EQUIP 4 4 5 INVESTMENT INCOME-OTHER 5 6 TRADE, QUANTITY, AND TIME DISCOUNTS 6 7 REFUNDS AND REBATES OF EXPENSES 7 8 RENTAL OF PROVIDER SPACE BY SUPPLIERS 8 9 TELEPHONE SERVICES (PAY STATIONS EXCL) 9 10 TELEVISION AND RADIO SERVICE B -5551 OPERATION OF PLANT 8 10 11 PARKING LOT 11 12 PROVIDER-BASED PHYSICIAN ADJUSTMENT WKST A-8-2 -4073489 12 13 SALE OF SCRAP, WASTE, ETC. 13 14 RELATED ORGANIZATION TRANSACTIONS WKST A-8-1 328492 14 15 LAUNDRY AND LINEN SERVICE 15 16 CAFETERIA - EMPLOYEES AND GUESTS B -1920444 CAFETERIA 12 16 17 RENTAL OF QUARTERS TO EMPLOYEES & OTHERS 17 18 SALE OF MEDICAL AND SURGICAL SUPPLIES TO OTHER THAN PATIENTS 18 19 SALE OF DRUGS TO OTHER THAN PATIENTS 19 20 SALE OF MEDICAL RECORDS AND ABSTRACTS B -76420 MEDICAL RECORDS & LIBRARY 17 20 21 NURSING SCHOOL (TUITION,FEES,BOOKS,ETC.) 21 22 VENDING MACHINES 22 23 INCOME FROM IMPOSITION OF INTEREST, FINANCE OR PENALTY CHARGES 23 24 INTEREST EXP ON MEDICARE OVERPAYMENTS & BORROWINGS TO REPAY MEDICARE OVERPAYMENT 24 25 ADJ FOR RESPIRATORY THERAPY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL A-8-4 RESPIRATORY THERAPY 49 25 26 ADJ FOR PHYSICAL THERAPY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL A-8-4 PHYSICAL THERAPY 50 26 27 ADJ FOR HHA PHYSICAL THERAPY COSTS IN WKST EXCESS OF LIMITATION A-8-3 HOME HEALTH AGENCY 71 27 28 UTIL REVIEW-PHYSICIANS' COMPENSATION UTILIZATION REVIEW-SNF 89 28 29 DEPRECIATION--OLD BUILDINGS & FIXTURES OLD CAP REL COSTS-BLDG & FIXT 1 29 30 DEPRECIATION--OLD MOVABLE EQUIPMENT OLD CAP REL COSTS-MVBLE EQUIP 2 30 31 DEPRECIATION--NEW BUILDINGS & FIXTURES NEW CAP REL COSTS-BLDG & FIXT 3 31 32 DEPRECIATION--NEW MOVABLE EQUIPMENT NEW CAP REL COSTS-MVBLE EQUIP 4 32 33 NON-PHYSICIAN ANESTHETIST NONPHYSICIAN ANESTHETISTS 20 33 34 PHYSICIANS' ASSISTANT 34 35 ADJ FOR OCCUPATIONAL THERAPY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL WKST A-8-4 35 36 ADJ FOR SPEECH PATHOLOGY COSTS IN WKST EXCESS OF LIMITATION - HOSPITAL WKST A-8-4 36 37 37 37.01 XRAY COPY B -5054 RADIOLOGY-DIAGNOSTIC 41 37.0137.10 DAY CARE CENTER B -1261543 EMPLOYEE BENEFITS 5 37.1037.13 EDUCATION REVENUE B -28648 PARAMED EDUC EMT PROGRAM 24.02 37.1337.17 MISC REVENUE - CYTOGENETICS B -621889 GENETIC SERVICES 59.10 37.1737.18 MISC ADMIN & GEN - OTHER OP INC B -2220918 ADMINISTRATIVE & GENERAL 6 37.1837.82 PATIENT PHONES A -1822 NEW CAP REL COSTS-BLDG & FIXT 3 9 37.8237.83 PATIENT PHONES A -563 EMPLOYEE BENEFITS 5 37.8337.84 PATIENT PHONES A -2922 CAFETERIA 12 37.8437.85 PATIENT PHONES A -173483 ADMINISTRATIVE & GENERAL 6 37.8537.86 PATIENT PHONES A -746 OPERATION OF PLANT 8 37.8637.87 PATIENT PHONES A -5068 HOUSEKEEPING 10 37.8737.88 PATIENT PHONES A -7647 NEW CAP REL COSTS-MVBLE EQUIP 4 9 37.8837.89 AHA & IHA LOBBY EXPENSE A -43362 ADMINISTRATIVE & GENERAL 6 37.8938 USEFUL LIFE CHG-SO MULFORD A -57670 NEW CAP REL COSTS-BLDG & FIXT 3 9 38 38.03 INTEREST EXPENSE A -3666166 ADMINISTRATIVE & GENERAL 6 38.0339 PHYSICIAN BILLING A -2457 ADMINISTRATIVE & GENERAL 6 39 40 REFERENCE LABORATORY B -7114888 LABORATORY 44 40 41 41 42 42 43 43 44 44 45 MISC REV B -5640 ADMINISTRATIVE & GENERAL 6 45 46 46 47 47 48 48 49 49 49.17 EMS REV B -62274 PARAMED EDUC EMT PROGRAM 24.02 49.1749.18 MISC REV B -21923 NEONATAL INTENSIVE CARE 29.01 49.1849.25 MISC REV B -220 CHILD PSYCHIATRIC CLINIC 60.03 49.25
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 ADJUSTMENTS TO EXPENSES WORKSHEET A-8 EXPENSE CLASSIFICATION ON WORKSHEET A TO/ FROM WHICH THE AMOUNT IS TO BE ADJUSTED WKST A-7 DESCRIPTION BASIS AMOUNT COST CENTER LINE NO. REF 1 2 3 4 5
49.26 MISC REV B -36623 WOMEN'S HEALTH ADVANTAGE 59.05 49.2649.28 PROPERTY TAXES A -128315 GUEST CENTER 100 49.2849.37 MISC REV B -53403 EMERGENCY 61 49.3749.42 MISC REV B -3656 PHYSICAL THERAPY 50 49.4249.43 MISC REV B -19828 OPERATION OF PLANT 8 49.4349.44 MISC REV B -8167 RESPIRATORY THERAPY 49 49.4449.45 MISC REV B -67785 ELECTROCARDIOLOGY 53 49.4549.46 MISC REV B -128164 RENAL DIALYSIS 57 49.4650 TOTAL -21498256 50
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND HOME OFFICE COSTS WORKSHEET A-8-1
A. COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR THE CLAIMING OF HOME OFFICE COSTS: AMOUNT OF AMOUNT (INCL NET ADJ- WKST LINE ALLOWABLE IN WKST A, USTMENTS A-7 NO. COST CENTER EXPENSE ITEMS COST COL 5) REF 1 2 3 4 5 6 7 1 8 OPERATION OF PLANT RMB RENT 1419 1419 1 2 37 OPERATING ROOM RMB RENT 27159 39684 -12525 2 3 41 RADIOLOGY-DIAGNOSTIC RMB RENT 3446 6912 -3466 3 4 53 ELECTROCARDIOLOGY RMB RENT 31719 46860 -15141 4 4.01 59.10 GENETIC SERVICES RMB RENT 37308 55392 -18084 4.01 4.02 6 ADMINISTRATIVE & GENERAL RHS MANAGEMENT FEE 4551595 4175306 376289 4.02 5 TOTALS 4652646 4324154 328492 5
B. INTERRELATIONSHIP OF RELATED ORGANIZATION(S) AND/OR HOME OFFICE:
THE SECRETARY, BY VIRTUE OF AUTHORITY GRANTED UNDER SECTION 1814(b)(1) OF THE SOCIAL SECURITY ACT, REQUIRES THAT YOUFURNISH THE INFORMATION REQUESTED UNDER PART B OF THIS WORKSHEET.
THE INFORMATION IS USED BY THE HEALTH CARE FINANCING ADMINISTRATION AND ITS INTERMEDIARIES IN DETERMINING THAT THE COSTSAPPLICABLE TO SERVICES, FACILITIES, AND SUPPLIES FURNISHED BY ORGANIZATIONS RELATED TO YOU BY COMMON OWNERSHIP OR CONTROLREPRESENT REASONABLE COSTS AS DETERMINED UNDER SECTION 1861 OF THE SOCIAL SECURITY ACT. IF YOU DO NOT PROVIDE ALL OR ANYPART OF THE REQUESTED INFORMATION, THE COST REPORT IS CONSIDERED INCOMPLETE AND NOT ACCEPTABLE FOR PURPOSES OF CLAIMINGREIMBURSEMENT UNDER TITLE XVIII. -------- RELATED ORGANIZATION(S) AND/OR HOME OFFICE ---------- PERCENT PERCENT SYMBOL NAME OF NAME OF TYPE OF (1) OWNERSHIP OWNERSHIP BUSINESS 1 2 3 4 5 6 1 E RKFD MEM DVLMT 100.00 SERVICE 1 2 E RMHSC PHYSICIAN CLINI 2 3 E FREEPORT MEM HO 50.00 MOBILE CATH LAB 3 4 B ROCKFORD HEALTH SYSTEM HOME OFFICE 4 5 B VAN MATER REHAB HOSPITAL VAN MATER REHAB HOSPITAL 50.00 REHAB HOSPITAL 5
(1) USE THE FOLLOWING SYMBOLS TO INDICATE THE INTERRELATIONSHIP TO RELATED ORGANIZATIONS: A. INDIVIDUAL HAS FINANCIAL INTEREST (STOCKHOLDER, PARTNER, ETC.) IN BOTH RELATED ORGANIZATION AND IN PROVIDER. B. CORPORATION, PARTNERSHIP, OR OTHER ORGANIZATION HAS FINANCIAL INTEREST IN PROVIDER. C. PROVIDER HAS FINANCIAL INTEREST IN CORPORATION, PARTNERSHIP, OR OTHER ORGANIZATION. D. DIRECTOR, OFFICER, ADMINISTRATOR, OR KEY PERSON OF PROVIDER OR RELATIVE OF SUCH PERSON HAS FINANCIAL INTEREST IN RELATED ORGANIZATION. E. INDIVIDUAL IS DIRECTOR, OFFICER, ADMINISTRATOR, OR KEY PERSON OF PROVIDER AND RELATED ORGANIZATION. F. DIRECTOR, OFFICER, ADMINISTRATOR, OR KEY PERSON OF RELATED ORGANIZATION OR RELATIVE OF SUCH PERSON HAS FINANCIAL INTEREST IN PROVIDER. G. OTHER (FINANCIAL OR NON-FINANCIAL) SPECIFY:
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 PROVIDER-BASED PHYSICIAN ADJUSTMENTS WORKSHEET A-8-2
1 5 EMPLOYEE BENEFITS PROFESSIONAL FEES 3241 3241 2 6 ADMINISTRATIVE & GENERAL PROFESSIONAL FEES 30000 30000 171400 250 20601 1030 3 6 ADMINISTRATIVE & GENERAL PROFESSIONAL FEES 1704488 1662821 41667 171400 416 34280 1714 4 6 ADMINISTRATIVE & GENERAL PROFESSIONAL FEES 90285 90285 171400 547 45075 2254 5 14 NURSING ADMINISTRATION PROFESSIONAL FEES 53000 53000 6 25 ADULTS & PEDIATRICS PROFESSIONAL FEES 14583 14583 7 25 ADULTS & PEDIATRICS PROFESSIONAL FEES 30000 30000 154100 416 30820 1541 8 26 INTENSIVE CARE UNIT PROFESSIONAL FEES 619196 589196 30000 171400 175 14421 721 9 29.01 NEONATAL INTENSIVE CARE PROFESSIONAL FEES 50000 50000 171400 416 34280 1714 10 29.02 PEDIATRIC INTENSIVE CARE PROFESSIONAL FEES 50000 50000 11 31 SUBPROVIDER I PROFESSIONAL FEES 90500 90500 12 37 OPERATING ROOM PROFESSIONAL FEES 75000 75000 204100 416 40820 2041 13 37 OPERATING ROOM PROFESSIONAL FEES 124902 54702 70200 204100 416 40820 2041 14 39 DELIVERY ROOM & LABOR RO PROFESSIONAL FEES 945294 915294 30000 194500 362 33850 1693 15 40 ANESTHESIOLOGY PROFESSIONAL FEES 995000 995000 200300 10840 1043871 52194 16 41 RADIOLOGY-DIAGNOSTIC PROFESSIONAL FEES 14585 14585 17 42 RADIOLOGY-THERAPEUTIC PROFESSIONAL FEES 50000 50000 219500 196 20684 1034 18 44 LABORATORY PROFESSIONAL FEES 388028 388028 204100 2080 204100 10205 19 49 RESPIRATORY THERAPY PROFESSIONAL FEES 14400 14400 204100 104 10205 510 20 49 RESPIRATORY THERAPY PROFESSIONAL FEES 7500 7500 204100 83 8144 407 21 60.02 ANTENATAL TEST CENTER PROFESSIONAL FEES 64583 64583 204100 375 36797 1840 22 61 EMERGENCY PROFESSIONAL FEES 270113 270113 204100 1324 129917 6496 23 65 AMBULANCE SERVICES PROFESSIONAL FEES 25000 25000 204100 152 14915 746 25 14 NURSING ADMINISTRATION PURCHASED LABOR 50 50 26 31 SUBPROVIDER I PURCHASED LABOR 55895 55895 27 37 OPERATING ROOM PURCHASED LABOR 1252950 1252950 241000 10840 1255981 62799 28 60.03 CHILD PSYCHIATRIC CLINIC PURCHASED LABOR 17261 17261 101 TOTAL 7035854 3521128 3514726 29408 3019581 150980
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 PROVIDER-BASED PHYSICIAN ADJUSTMENTS WORKSHEET A-8-2
WKST COST OF PROVIDER PHYSICIAN PROVIDER A COST CENTER/ MEMBERSHIP COMPONENT COST OF COMPONENT ADJUSTED RCE LINE PHYSICIAN IDENTIFIER & CONTIN. SHARE OF MALPRACTICE SHARE OF RCE DIS- ADJUST- NO. EDUCATION COLUMN 12 INSURANCE COLUMN 14 LIMIT ALLOWANCE MENT 10 11 12 13 14 15 16 17 18
1 5 EMPLOYEE BENEFITS PROFESSIONAL FEES 3241 2 6 ADMINISTRATIVE & GENERAL PROFESSIONAL FEES 20601 9399 9399 3 6 ADMINISTRATIVE & GENERAL PROFESSIONAL FEES 34280 7387 1670208 4 6 ADMINISTRATIVE & GENERAL PROFESSIONAL FEES 45075 45210 45210 5 14 NURSING ADMINISTRATION PROFESSIONAL FEES 53000 6 25 ADULTS & PEDIATRICS PROFESSIONAL FEES 14583 7 25 ADULTS & PEDIATRICS PROFESSIONAL FEES 30820 8 26 INTENSIVE CARE UNIT PROFESSIONAL FEES 14421 15579 604775 9 29.01 NEONATAL INTENSIVE CARE PROFESSIONAL FEES 34280 15720 15720 10 29.02 PEDIATRIC INTENSIVE CARE PROFESSIONAL FEES 50000 11 31 SUBPROVIDER I PROFESSIONAL FEES 90500 12 37 OPERATING ROOM PROFESSIONAL FEES 40820 34180 34180 13 37 OPERATING ROOM PROFESSIONAL FEES 40820 29380 84082 14 39 DELIVERY ROOM & LABOR RO PROFESSIONAL FEES 33850 915294 15 40 ANESTHESIOLOGY PROFESSIONAL FEES 1043871 16 41 RADIOLOGY-DIAGNOSTIC PROFESSIONAL FEES 14585 17 42 RADIOLOGY-THERAPEUTIC PROFESSIONAL FEES 20684 29316 29316 18 44 LABORATORY PROFESSIONAL FEES 204100 183928 183928 19 49 RESPIRATORY THERAPY PROFESSIONAL FEES 10205 4195 4195 20 49 RESPIRATORY THERAPY PROFESSIONAL FEES 8144 21 60.02 ANTENATAL TEST CENTER PROFESSIONAL FEES 36797 27786 27786 22 61 EMERGENCY PROFESSIONAL FEES 129917 140196 140196 23 65 AMBULANCE SERVICES PROFESSIONAL FEES 14915 10085 10085 25 14 NURSING ADMINISTRATION PURCHASED LABOR 50 26 31 SUBPROVIDER I PURCHASED LABOR 55895 27 37 OPERATING ROOM PURCHASED LABOR 1255981 28 60.03 CHILD PSYCHIATRIC CLINIC PURCHASED LABOR 17261101 TOTAL 3019581 552361 4073489
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I
NET EXP NEW CAP NEW CAP EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION FOR COST BLDGS & MOVABLE BENEFITS SUBTOTAL TRATIVE & OF PLANT & LINEN ALLOCATION FIXTURES EQUIPMENT GENERAL SERVICE 0 3 4 5 5A 6 8 9
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I
NET EXP NEW CAP NEW CAP EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION FOR COST BLDGS & MOVABLE BENEFITS SUBTOTAL TRATIVE & OF PLANT & LINEN ALLOCATION FIXTURES EQUIPMENT GENERAL SERVICE 0 3 4 5 5A 6 8 9
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I
HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL SOCIAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS + SERVICE TRATION SUPPLY LIBRARY 10 11 12 14 15 16 17 18
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I
HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL SOCIAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS + SERVICE TRATION SUPPLY LIBRARY 10 11 12 14 15 16 17 18
69.30 OUTPATIENT OCCUPATIONAL THERAPY 69.3069.40 OUTPATIENT SPEECH PATHOLOGY 69.4071 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS85.01 PANCREAS ACQUISITION 85.0185.02 INTESTINAL ACQUISITION 85.0285.03 ISLET CELL ACQUISITION 85.0395 SUBTOTALS 4217685 3251634 2761408 4381179 4900257 7057722 4696756 492633 95 NONREIMBURSABLE COST CENTERS98 PHYSICIANS' PRIVATE OFFICES 98 100 GUEST CENTER 54877 3153 100 100.01OTHER NONREIMBURSEABLE COST CEN 100.01100.02COMMUNITY SERVICES 40716 12434 7665 100.02100.04AUXILIARY 110995 6445 100.04100.07ROCKFORD HEALTH SYSTEM 100.07100.08DIALYSIS RENTED SPACE 100.08101 CROSS FOOT ADJUSTMENTS 101102 NEGATIVE COST CENTER 102103 TOTAL 4424273 3251634 2783440 4388844 4900257 7057722 4696756 492633 103
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I
PARAMEDICA PASTORAL PARA MED I&R COST & COST CENTER DESCRIPTION EDUCATION EDUCATION EDUC SUBTOTAL POST STEP- TOTAL XRAY PROGRAM EMT DOWN ADJS 24 24.01 24.02 25 26 27
GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 11 12 CAFETERIA 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 14 15 CENTRAL SERVICES & SUPPLY 15 16 PHARMACY 16 17 MEDICAL RECORDS & LIBRARY 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMDICAL ED PROGRAM XRAY 600475 24 24.01 PASTORAL EDUCATION PROGRAM 111431 24.0124.02 PARAMED EDUC EMT PROGRAM 1046578 24.02 INPATIENT ROUTINE SERV COST CENTERS25 ADULTS & PEDIATRICS 74377 27800 51482606 51482606 25 26 INTENSIVE CARE UNIT 7358 55599 10822483 10822483 26 29.01 NEONATAL INTENSIVE CARE 18490 13009881 13009881 29.0129.02 PEDIATRIC INTENSIVE CARE 1703 1840170 1840170 29.0231 SUBPROVIDER I 3915 2731519 2731519 31 33 NURSERY 5588 2742231 2742231 33 ANCILLARY SERVICE COST CENTERS37 OPERATING ROOM 145540 23658891 23658891 37 38 RECOVERY ROOM 2283153 2283153 38 39 DELIVERY ROOM & LABOR ROOM 27800 5808851 5808851 39 40 ANESTHESIOLOGY 3884596 3884596 40 41 RADIOLOGY-DIAGNOSTIC 600475 9450983 9450983 41 42 RADIOLOGY-THERAPEUTIC 2802493 2802493 42 43 RADIOISOTOPE 1397295 1397295 43 44 LABORATORY 14792092 14792092 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.3047 BLOOD STORING, PROCESSING & TRA 2805877 2805877 47 49 RESPIRATORY THERAPY 21259 6986669 6986669 49 50 PHYSICAL THERAPY 2351069 2351069 50 53 ELECTROCARDIOLOGY 2777599 2777599 53 54 ELECTROENCEPHALOGRAPHY 257095 257095 54 55 MEDICAL SUPPLIES CHARGED TO PAT 23261078 23261078 55 56 DRUGS CHARGED TO PATIENTS 19491086 19491086 56 57 RENAL DIALYSIS 884006 884006 57 59 GI LAB 2087278 2087278 59 59.01 MRI 2024170 2024170 59.0159.02 CT SCAN 2104948 2104948 59.0259.03 CARDIAC CATHETERIZATION 7572826 7572826 59.0359.04 PRIMARY PREVENTION PROGRAM 59.0459.05 WOMEN'S HEALTH ADVANTAGE 97402 97402 59.0559.07 OUTPATIENT DETOX 59.0759.08 SPECIAL SURGICAL SERVICES 620650 620650 59.0859.10 GENETIC SERVICES 1060237 1060237 59.1059.11 CARDIOLOGY 59.1159.12 OUTPATIENT PSYCH SERVICES 59.12 OUTPATIENT SERVICE COST CENTERS60.01 PAIN CENTER 2519080 2519080 60.0160.02 ANTENATAL TEST CENTER 1177121 1177121 60.0260.03 CHILD PSYCHIATRIC CLINIC 961370 961370 60.0361 EMERGENCY 768580 13846319 13846319 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.5063.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS65 AMBULANCE SERVICES 4001857 4001857 65 68 AIR AMBULANCE 68 69.10 CMHC 69.1069.20 OUTPATIENT PHYSICAL THERAPY 69.20
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - GENERAL SERVICE COSTS WORKSHEET B PART I
PARAMEDICA PASTORAL PARA MED I&R COST & COST CENTER DESCRIPTION EDUCATION EDUCATION EDUC SUBTOTAL POST STEP- TOTAL XRAY PROGRAM EMT DOWN ADJS 24 24.01 24.02 25 26 27
69.30 OUTPATIENT OCCUPATIONAL THERAPY 69.3069.40 OUTPATIENT SPEECH PATHOLOGY 69.4071 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS85.01 PANCREAS ACQUISITION 85.0185.02 INTESTINAL ACQUISITION 85.0285.03 ISLET CELL ACQUISITION 85.0395 SUBTOTALS 600475 111431 1046578 243594981 243594981 95 NONREIMBURSABLE COST CENTERS98 PHYSICIANS' PRIVATE OFFICES 1554614 1554614 98 100 GUEST CENTER 539110 539110 100 100.01OTHER NONREIMBURSEABLE COST CEN 100.01100.02COMMUNITY SERVICES 2029386 2029386 100.02100.04AUXILIARY 1171138 1171138 100.04100.07ROCKFORD HEALTH SYSTEM 100.07100.08DIALYSIS RENTED SPACE 100.08101 CROSS FOOT ADJUSTMENTS 101102 NEGATIVE COST CENTER 102103 TOTAL 600475 111431 1046578 248889229 248889229 103
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III
DIR ASSGND NEW CAP NEW CAP CAP REL EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION CAP-REL BLDGS & MOVABLE COST TO BENEFITS TRATIVE & OF PLANT & LINEN COSTS FIXTURES EQUIPMENT BE ALLOC GENERAL SERVICE 0 3 4 4A 5 6 8 9
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III
DIR ASSGND NEW CAP NEW CAP CAP REL EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION CAP-REL BLDGS & MOVABLE COST TO BENEFITS TRATIVE & OF PLANT & LINEN COSTS FIXTURES EQUIPMENT BE ALLOC GENERAL SERVICE 0 3 4 4A 5 6 8 9
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III
HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL SOCIAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS + SERVICE TRATION SUPPLY LIBRARY 10 11 12 14 15 16 17 18
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III
HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL SOCIAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS + SERVICE TRATION SUPPLY LIBRARY 10 11 12 14 15 16 17 18
69.30 OUTPATIENT OCCUPATIONAL THERAPY 69.3069.40 OUTPATIENT SPEECH PATHOLOGY 69.4071 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS85.01 PANCREAS ACQUISITION 85.0185.02 INTESTINAL ACQUISITION 85.0285.03 ISLET CELL ACQUISITION 85.0395 SUBTOTALS 152015 188613 209335 157025 996555 997016 196631 16048 95 NONREIMBURSABLE COST CENTERS98 PHYSICIANS' PRIVATE OFFICES 98 100 GUEST CENTER 1978 239 100 100.01OTHER NONREIMBURSEABLE COST CEN 100.01100.02COMMUNITY SERVICES 1467 943 275 100.02100.04AUXILIARY 4000 489 100.04100.07ROCKFORD HEALTH SYSTEM 100.07100.08DIALYSIS RENTED SPACE 100.08101 CROSS FOOT ADJUSTMENTS 101102 NEGATIVE COST CENTER 102103 TOTAL 159460 188613 211006 157300 996555 997016 196631 16048 103
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III
PARAMEDICA PASTORAL PARA MED I&R COST & COST CENTER DESCRIPTION EDUCATION EDUCATION EDUC SUBTOTAL POST STEP- TOTAL XRAY PROGRAM EMT DOWN ADJS 24 24.01 24.02 25 26 27
GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 11 12 CAFETERIA 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 14 15 CENTRAL SERVICES & SUPPLY 15 16 PHARMACY 16 17 MEDICAL RECORDS & LIBRARY 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMDICAL ED PROGRAM XRAY 25487 24 24.01 PASTORAL EDUCATION PROGRAM 5066 24.0124.02 PARAMED EDUC EMT PROGRAM 74714 24.02 INPATIENT ROUTINE SERV COST CENTERS25 ADULTS & PEDIATRICS 2890303 2890303 25 26 INTENSIVE CARE UNIT 458172 458172 26 29.01 NEONATAL INTENSIVE CARE 554024 554024 29.0129.02 PEDIATRIC INTENSIVE CARE 117484 117484 29.0231 SUBPROVIDER I 170539 170539 31 33 NURSERY 102328 102328 33 ANCILLARY SERVICE COST CENTERS37 OPERATING ROOM 1718059 1718059 37 38 RECOVERY ROOM 86706 86706 38 39 DELIVERY ROOM & LABOR ROOM 429643 429643 39 40 ANESTHESIOLOGY 142035 142035 40 41 RADIOLOGY-DIAGNOSTIC 1453567 1453567 41 42 RADIOLOGY-THERAPEUTIC 348334 348334 42 43 RADIOISOTOPE 69063 69063 43 44 LABORATORY 1011600 1011600 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.3047 BLOOD STORING, PROCESSING & TRA 70706 70706 47 49 RESPIRATORY THERAPY 540040 540040 49 50 PHYSICAL THERAPY 86485 86485 50 53 ELECTROCARDIOLOGY 214687 214687 53 54 ELECTROENCEPHALOGRAPHY 31459 31459 54 55 MEDICAL SUPPLIES CHARGED TO PAT 1374852 1374852 55 56 DRUGS CHARGED TO PATIENTS 1253454 1253454 56 57 RENAL DIALYSIS 55015 55015 57 59 GI LAB 278891 278891 59 59.01 MRI 370687 370687 59.0159.02 CT SCAN 281194 281194 59.0259.03 CARDIAC CATHETERIZATION 656164 656164 59.0359.04 PRIMARY PREVENTION PROGRAM 59.0459.05 WOMEN'S HEALTH ADVANTAGE 13475 13475 59.0559.07 OUTPATIENT DETOX 59.0759.08 SPECIAL SURGICAL SERVICES 19931 19931 59.0859.10 GENETIC SERVICES 103129 103129 59.1059.11 CARDIOLOGY 59.1159.12 OUTPATIENT PSYCH SERVICES 59.12 OUTPATIENT SERVICE COST CENTERS60.01 PAIN CENTER 185626 185626 60.0160.02 ANTENATAL TEST CENTER 156077 156077 60.0260.03 CHILD PSYCHIATRIC CLINIC 34416 34416 60.0361 EMERGENCY 766020 766020 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.5063.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS65 AMBULANCE SERVICES 146671 146671 65 68 AIR AMBULANCE 68 69.10 CMHC 69.1069.20 OUTPATIENT PHYSICAL THERAPY 69.20
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 ALLOCATION OF NEW CAPITAL RELATED COSTS WORKSHEET B PART III
PARAMEDICA PASTORAL PARA MED I&R COST & COST CENTER DESCRIPTION EDUCATION EDUCATION EDUC SUBTOTAL POST STEP- TOTAL XRAY PROGRAM EMT DOWN ADJS 24 24.01 24.02 25 26 27
69.30 OUTPATIENT OCCUPATIONAL THERAPY 69.3069.40 OUTPATIENT SPEECH PATHOLOGY 69.4071 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS85.01 PANCREAS ACQUISITION 85.0185.02 INTESTINAL ACQUISITION 85.0285.03 ISLET CELL ACQUISITION 85.0395 SUBTOTALS 16190836 16190836 95 NONREIMBURSABLE COST CENTERS98 PHYSICIANS' PRIVATE OFFICES 30953 30953 98 100 GUEST CENTER 53327 53327 100 100.01OTHER NONREIMBURSEABLE COST CEN 100.01100.02COMMUNITY SERVICES 63893 63893 100.02100.04AUXILIARY 92557 92557 100.04100.07ROCKFORD HEALTH SYSTEM 100.07100.08DIALYSIS RENTED SPACE 100.08101 CROSS FOOT ADJUSTMENTS 25487 5066 74714 105267 105267 101102 NEGATIVE COST CENTER 102103 TOTAL 25487 5066 74714 16536833 16536833 103
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1
NEW CAP NEW CAP EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION BLDGS & MOVABLE BENEFITS RECON- TRATIVE & OF PLANT & LINEN FIXTURES EQUIPMENT CILIATION GENERAL SERVICE SQUARE DOLLAR GROSS ACCUM SQUARE POUNDS OF FEET VALUE SALARIES COST FEET LAUNDRY 3 4 5 6A 6 8 9
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1
NEW CAP NEW CAP EMPLOYEE ADMINIS- OPERATION LAUNDRY COST CENTER DESCRIPTION BLDGS & MOVABLE BENEFITS RECON- TRATIVE & OF PLANT & LINEN FIXTURES EQUIPMENT CILIATION GENERAL SERVICE SQUARE DOLLAR GROSS ACCUM SQUARE POUNDS OF FEET VALUE SALARIES COST FEET LAUNDRY 3 4 5 6A 6 8 9
69.10 CMHC 69.10 69.20 OUTPATIENT PHYSICAL THERAPY 69.20 69.30 OUTPATIENT OCCUPATIONAL THERA 69.30 69.40 OUTPATIENT SPEECH PATHOLOGY 69.40 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 85.03 ISLET CELL ACQUISITION 85.03 95 SUBTOTALS 719213 15092493 101134856 -49127054 196164900 415332 933926 95 NONREIMBURSABLE COST CENTERS 98 PHYSICIANS' PRIVATE OFFICES 1247756 98 100 GUEST CENTER 5216 14634 59948 254903 5216 7946 100 100.01 OTHER NONREIMBURSEABLE COST C 100.01100.02 COMMUNITY SERVICES 3870 309141 1491144 3870 100.02100.04 AUXILIARY 10550 9789 93046 603472 10550 100.04100.07 ROCKFORD HEALTH SYSTEM 100.07100.08 DIALYSIS RENTED SPACE 100.08101 CROSS FOOT ADJUSTMENTS 101102 NEGATIVE COST CENTER 102103 COST TO BE ALLOC PER B PT I 2898290 12390945 5167081 49127054 12443576 1691477 103104 UNIT COST MULT-WS B PT I .819674 28.608026 104104 UNIT COST MULT-WS B PT I 3.922710 .050859 .245928 1.795867 104105 COST TO BE ALLOC PER B PT II 105106 UNIT COST MULT-WS B PT II 106106 UNIT COST MULT-WS B PT II 106107 COST TO BE ALLOC PER B PT III 127791 4955445 971860 71411 107108 UNIT COST MULT-WS B PT III 2.234325 108108 UNIT COST MULT-WS B PT III .001258 .024807 .075818 108
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1
HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL SOCIAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS + SERVICE TRATION SUPPLY LIBRARY SQUARE MEALS FTE'S DIRECT COSTED COSTED GROSS VISITS FEET SERVED NRSING HRS REQUIS. REQUIS. REVENUE 10 11 12 14 15 16 17 18
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1
HOUSE- DIETARY CAFETERIA NURSING CENTRAL PHARMACY MEDICAL SOCIAL COST CENTER DESCRIPTION KEEPING ADMINIS- SERVICES & RECORDS + SERVICE TRATION SUPPLY LIBRARY SQUARE MEALS FTE'S DIRECT COSTED COSTED GROSS VISITS FEET SERVED NRSING HRS REQUIS. REQUIS. REVENUE 10 11 12 14 15 16 17 18
69.10 CMHC 69.10 69.20 OUTPATIENT PHYSICAL THERAPY 69.20 69.30 OUTPATIENT OCCUPATIONAL THERA 69.30 69.40 OUTPATIENT SPEECH PATHOLOGY 69.40 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 85.03 ISLET CELL ACQUISITION 85.03 95 SUBTOTALS 400887 208226 139247 1229431 100 100 691516779 8784 95 NONREIMBURSABLE COST CENTERS 98 PHYSICIANS' PRIVATE OFFICES 98 100 GUEST CENTER 5216 159 100 100.01 OTHER NONREIMBURSEABLE COST C 100.01100.02 COMMUNITY SERVICES 3870 627 2151 100.02100.04 AUXILIARY 10550 325 100.04100.07 ROCKFORD HEALTH SYSTEM 100.07100.08 DIALYSIS RENTED SPACE 100.08101 CROSS FOOT ADJUSTMENTS 101102 NEGATIVE COST CENTER 102103 COST TO BE ALLOC PER B PT I 4424273 3251634 2783440 4388844 4900257 7057722 4696756 492633 103104 UNIT COST MULT-WS B PT I 10.520882 19.831004 49002.570000 .006792 104104 UNIT COST MULT-WS B PT I 15.615889 3.563582 70577.220000 56.082992 104105 COST TO BE ALLOC PER B PT II 105106 UNIT COST MULT-WS B PT II 106106 UNIT COST MULT-WS B PT II 106107 COST TO BE ALLOC PER B PT III 159460 188613 211006 157300 996555 997016 196631 16048 107108 UNIT COST MULT-WS B PT III .379194 1.503341 9965.550000 .000284 108108 UNIT COST MULT-WS B PT III .905809 .127722 9970.160000 1.826958 108
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1
PARAMEDICA PASTORAL PARA MED COST CENTER DESCRIPTION EDUCATION EDUCATION EDUC XRAY PROGRAM EMT ASSIGNED PATIENT TIME TIME DAYS SPENT 24 24.01 24.02
GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 11 12 CAFETERIA 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 14 15 CENTRAL SERVICES & SUPPLY 15 16 PHARMACY 16 17 MEDICAL RECORDS & LIBRARY 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES 22 23 I&R SERVICES-OTHER PRGM COSTS 23 24 PARAMDICAL ED PROGRAM XRAY 100 24 24.01 PASTORAL EDUCATION PROGRAM 77326 24.01 24.02 PARAMED EDUC EMT PROGRAM 640 24.02 INPATIENT ROUTINE SERV COST CENTERS 25 ADULTS & PEDIATRICS 51612 17 25 26 INTENSIVE CARE UNIT 5106 34 26 29.01 NEONATAL INTENSIVE CARE 12831 29.01 29.02 PEDIATRIC INTENSIVE CARE 1182 29.02 31 SUBPROVIDER I 2717 31 33 NURSERY 3878 33 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM 89 37 38 RECOVERY ROOM 38 39 DELIVERY ROOM & LABOR ROOM 17 39 40 ANESTHESIOLOGY 40 41 RADIOLOGY-DIAGNOSTIC 100 41 42 RADIOLOGY-THERAPEUTIC 42 43 RADIOISOTOPE 43 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN 46.30 47 BLOOD STORING, PROCESSING & T 47 49 RESPIRATORY THERAPY 13 49 50 PHYSICAL THERAPY 50 53 ELECTROCARDIOLOGY 53 54 ELECTROENCEPHALOGRAPHY 54 55 MEDICAL SUPPLIES CHARGED TO P 55 56 DRUGS CHARGED TO PATIENTS 56 57 RENAL DIALYSIS 57 59 GI LAB 59 59.01 MRI 59.01 59.02 CT SCAN 59.02 59.03 CARDIAC CATHETERIZATION 59.03 59.04 PRIMARY PREVENTION PROGRAM 59.04 59.05 WOMEN'S HEALTH ADVANTAGE 59.05 59.07 OUTPATIENT DETOX 59.07 59.08 SPECIAL SURGICAL SERVICES 59.08 59.10 GENETIC SERVICES 59.10 59.11 CARDIOLOGY 59.11 59.12 OUTPATIENT PSYCH SERVICES 59.12 OUTPATIENT SERVICE COST CENTERS 60.01 PAIN CENTER 60.01 60.02 ANTENATAL TEST CENTER 60.02 60.03 CHILD PSYCHIATRIC CLINIC 60.03 61 EMERGENCY 470 61 62 OBSERVATION BEDS (NON-DISTINC 62 63.50 RHC 63.50 63.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS 65 AMBULANCE SERVICES 65 68 AIR AMBULANCE 68
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 COST ALLOCATION - STATISTICAL BASIS WORKSHEET B-1
PARAMEDICA PASTORAL PARA MED COST CENTER DESCRIPTION EDUCATION EDUCATION EDUC XRAY PROGRAM EMT ASSIGNED PATIENT TIME TIME DAYS SPENT 24 24.01 24.02
69.10 CMHC 69.10 69.20 OUTPATIENT PHYSICAL THERAPY 69.20 69.30 OUTPATIENT OCCUPATIONAL THERA 69.30 69.40 OUTPATIENT SPEECH PATHOLOGY 69.40 71 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS 85.01 PANCREAS ACQUISITION 85.01 85.02 INTESTINAL ACQUISITION 85.02 85.03 ISLET CELL ACQUISITION 85.03 95 SUBTOTALS 100 77326 640 95 NONREIMBURSABLE COST CENTERS 98 PHYSICIANS' PRIVATE OFFICES 98 100 GUEST CENTER 100 100.01 OTHER NONREIMBURSEABLE COST C 100.01100.02 COMMUNITY SERVICES 100.02100.04 AUXILIARY 100.04100.07 ROCKFORD HEALTH SYSTEM 100.07100.08 DIALYSIS RENTED SPACE 100.08101 CROSS FOOT ADJUSTMENTS 101102 NEGATIVE COST CENTER 102103 COST TO BE ALLOC PER B PT I 600475 111431 1046578 103104 UNIT COST MULT-WS B PT I 6004.750000 1635.278125 104104 UNIT COST MULT-WS B PT I 1.441055 104105 COST TO BE ALLOC PER B PT II 105106 UNIT COST MULT-WS B PT II 106106 UNIT COST MULT-WS B PT II 106107 COST TO BE ALLOC PER B PT III 25487 5066 74714 107108 UNIT COST MULT-WS B PT III 254.870000 116.740625 108108 UNIT COST MULT-WS B PT III .065515 108
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (5/1999) 05/23/2009 10:27 COMPUTATION OF RATIO OF COST TO CHARGES WORKSHEET C PART I
TOTAL COST THERAPY COST CENTER DESCRIPTION (FROM WKST B, LIMIT TOTAL RCE TOTAL PART I, COL 27) ADJUSTMENT COSTS DISALLOWANCE COSTS 1 2 3 4 5
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (5/1999) 05/23/2009 10:27 COMPUTATION OF RATIO OF COST TO CHARGES WORKSHEET C PART I (CONT)
-------------- CHARGES --------------- COST TEFRA PPS COST CENTER DESCRIPTION OR OTHER INPATIENT INPATIENT INPATIENT OUTPATIENT TOTAL RATIO RATIO RATIO 6 7 8 9 10 11
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS WORKSHEET D PART I
CHECK [ ] TITLE V APPLICABLE [XX] TITLE XVIII-PT ABOXES [ ] TITLE XIX ---------- OLD CAPITAL ---------- ---------- NEW CAPITAL ---------- REDUCED REDUCED CAPITAL SWING-BED CAPITAL CAPITAL SWING-BED CAPITAL COST CENTER DESCRIPTION RELATED ADJUSTMENT RELATED RELATED ADJUSTMENT RELATED COST COST COST COST 1 2 3 4 5 6
INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 2890303 2890303 25 26 INTENSIVE CARE UNIT 458172 458172 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 29.01 NEONATAL INTENSIVE CARE 554024 554024 29.01 29.02 PEDIATRIC INTENSIVE CARE 117484 117484 29.02 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 170539 170539 31 33 NURSERY 102328 102328 33 101 TOTAL 4292850 4292850 101
---- OLD CAPITAL ---- ---- NEW CAPITAL ---- INPATIENT INPATIENT TOTAL INPATIENT PER PROGRAM PER PROGRAM COST CENTER DESCRIPTION PATIENT PROGRAM DIEM CAPITAL DIEM CAPITAL DAYS DAYS COST COST 7 8 9 10 11 12
INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 55150 23893 52.41 1252232 25 26 INTENSIVE CARE UNIT 5794 3245 79.08 256615 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 29.01 NEONATAL INTENSIVE CARE 12208 45.38 29.01 29.02 PEDIATRIC INTENSIVE CARE 908 129.39 29.02 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 2958 711 57.65 40989 31 33 NURSERY 3863 26.49 33 101 TOTAL 80881 27849 1549836 101
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS WORKSHEET D PART II
CHECK [ ] TITLE V [XX] HOSPITAL (14-0239) [ ] SUB III [XX] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SUB IV [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II
OLD NEW ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- CAPITAL CAPITAL INPATIENT RATIO OF RATIO OF COST CENTER DESCRIPTION RELATED RELATED TOTAL PROGRAM COST TO CAPITAL COST TO CAPITAL COST COST CHARGES CHARGES CHARGES COSTS CHARGES COSTS 1 2 3 4 5 6 7 8
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART III
CHECK [ ] TITLE V APPLICABLE [XX] TITLE XVIII-PT ABOXES [ ] TITLE XIX ALL OTHER NONPHYSICIAN NURSING ALLIED MEDICAL SWING-BED COST CENTER DESCRIPTION ANESTHETIST SCHOOL HEALTH EDUCATION ADJUSTMENT TOTAL COST COST COSTS COSTS AMOUNT COSTS 1 2 2.01 2.02 3 4
INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 102177 102177 25 26 INTENSIVE CARE UNIT 62957 62957 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 29.01 NEONATAL INTENSIVE CARE 18490 18490 29.01 29.02 PEDIATRIC INTENSIVE CARE 1703 1703 29.02 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 3915 3915 31 33 NURSERY 5588 5588 33 34 SKILLED NURSING FACILITY 34 35 NURSING FACILITY 35 101 TOTAL 194830 194830 101
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART III
CHECK [ ] TITLE V APPLICABLE [XX] TITLE XVIII-PT ABOXES [ ] TITLE XIX INPATIENT TOTAL INPATIENT PROGRAM COST CENTER DESCRIPTION PATIENT PER PROGRAM PASS THRU DAYS DIEM DAYS COSTS 5 6 7 8
INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 55150 1.85 23893 44202 25 26 INTENSIVE CARE UNIT 5794 10.87 3245 35273 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 29.01 NEONATAL INTENSIVE CARE 12208 1.51 29.01 29.02 PEDIATRIC INTENSIVE CARE 908 1.88 29.02 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 2958 1.32 711 939 31 33 NURSERY 3863 1.45 33 34 SKILLED NURSING FACILITY 34 35 NURSING FACILITY 35 101 TOTAL 80881 27849 80414 101
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [XX] HOSPITAL (14-0239) [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR
OUTPATIENT ALL OTHER NONPHYSICIAN NONPHYSICIAN NURSING ALLIED MEDICAL ADMINISTERING COST CENTER DESCRIPTION ANESTHETIST ANESTHETIST SCHOOL HEALTH EDUCATION BLOOD CLOTTING TOTAL COST COST COST COSTS COSTS FACTORS COST COSTS 1 1.01 2 2.01 2.02 2.03 3
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [XX] HOSPITAL (14-0239) [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR
INPATIENT OUTPATIENT RATIO OF OUTPATIENT INPATIENT PROGRAM OUTPATIENT COST CENTER DESCRIPTION PASS THROUGH TOTAL COST TO RATIO OF COST PROGRAM PASS THROUGH PROGRAM COSTS CHARGES CHARGES TO CHARGES CHARGES COSTS CHARGES 3.01 4 5 5.01 6 7 8
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [XX] HOSPITAL (14-0239) [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR
OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT PROGRAM PROGRAM PROGRAM COST CENTER DESCRIPTION PROGRAM PROGRAM PASS THROUGH PASS THROUGH PASS THROUGH CHARGES CHARGES COSTS COSTS COSTS 8.01 8.02 9 9.01 9.02
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/23/2009 10:27 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI
CHECK [ ] TITLE V - O/P [XX] HOSPITAL (14-0239) [ ] SNF APPLICABLE [XX] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [ ] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR
--------- PROGRAM CHARGES ---------- OUTPATIENT COST TO CHARGE RATIO FROM WORKSHEET C, AMBULATORY OTHER COST CENTER DESCRIPTION PART II PART I PART II SURGICAL OUTPATIENT OUTPATIENT COL. 8 COL. 9 COL. 9 CENTER RADIOLOGY DIAGNOSTIC 1 1.01 1.02 2 3 4
PART VI - VACCINE COST APPORTIONMENT 1 1 DRUGS CHARGED TO PATIENTS - RATIO OF COST TO CHARGES .326378 1 2 PROGRAM VACCINE CHARGES 2321 2 2.01 PROGRAM VACCINE CHARGES 2.01 3 PROGRAM COSTS 758 3 3.01 PROGRAM COSTS 3.01
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/23/2009 10:27 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI
CHECK [ ] TITLE V - O/P [XX] HOSPITAL (14-0239) [ ] SNF APPLICABLE [XX] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [ ] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR
------------------ PROGRAM CHARGES ------------------- --------- PROGRAM COST --------- ALL PPS SER- PPS SER- PPS SER- OUTPATIENT OTHER (1) VICES ALL OTHER VICES VICES AMBULATORY OTHER COST CENTER DESCRIPTION (SEE (SEE (SEE (SEE (SEE SURGICAL OUTPATIENT OUTPATIENT INSTRU.) INSTRU.) INSTRU.) INSTRU.) INSTRU.) CENTER RADIOLOGY DIAGNOSTIC 5 5.01 5.02 5.03 5.04 6 7 8
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (8/2002) 05/23/2009 10:27 APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES AND VACCINE COST WORKSHEET D PARTS V & VI
CHECK [ ] TITLE V - O/P [XX] HOSPITAL (14-0239) [ ] SNF APPLICABLE [XX] TITLE XVIII-PT B [ ] SUB I [ ] NF BOXES [ ] TITLE XIX - O/P [ ] SUB II [ ] S/B-SNF [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR
-------------------- PROGRAM COST -------------------- HOSPITAL HOSPITAL PPS PPS PPS I/P PART B I/P PART B SERVICES ALL OTHER SERVICES SERVICES CHARGES COST COST CENTER DESCRIPTION ALL OTHER (COLUMNS (COLUMNS (COLUMNS (COLUMNS (SEE (COLUMNS (COLS 1x5) 1.01x5.01) 1.01x5.02) 1.01x5.03 1.01x5.04 INSTRU.) 1.02x10) 9 9.01 9.02 9.03 9.04 10 11
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS WORKSHEET D PART II
CHECK [ ] TITLE V [ ] HOSPITAL [ ] SUB III [XX] PPS APPLICABLE [XX] TITLE XVIII-PT A [XX] SUB I (14-S239) [ ] SUB IV [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II
OLD NEW ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- CAPITAL CAPITAL INPATIENT RATIO OF RATIO OF COST CENTER DESCRIPTION RELATED RELATED TOTAL PROGRAM COST TO CAPITAL COST TO CAPITAL COST COST CHARGES CHARGES CHARGES COSTS CHARGES COSTS 1 2 3 4 5 6 7 8
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [ ] HOSPITAL [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [XX] SUB I (14-S239) [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR
OUTPATIENT ALL OTHER NONPHYSICIAN NONPHYSICIAN NURSING ALLIED MEDICAL ADMINISTERING COST CENTER DESCRIPTION ANESTHETIST ANESTHETIST SCHOOL HEALTH EDUCATION BLOOD CLOTTING TOTAL COST COST COST COSTS COSTS FACTORS COST COSTS 1 1.01 2 2.01 2.02 2.03 3
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [ ] HOSPITAL [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [XX] SUB I (14-S239) [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR
INPATIENT OUTPATIENT RATIO OF OUTPATIENT INPATIENT PROGRAM OUTPATIENT COST CENTER DESCRIPTION PASS THROUGH TOTAL COST TO RATIO OF COST PROGRAM PASS THROUGH PROGRAM COSTS CHARGES CHARGES TO CHARGES CHARGES COSTS CHARGES 3.01 4 5 5.01 6 7 8
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [ ] HOSPITAL [ ] SUB IV [ ] PPS APPLICABLE [XX] TITLE XVIII-PT A [XX] SUB I (14-S239) [ ] SNF [ ] TEFRA BOXES [ ] TITLE XIX [ ] SUB II [ ] NF [ ] SUB III [ ] ICF/MR
OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT PROGRAM PROGRAM PROGRAM COST CENTER DESCRIPTION PROGRAM PROGRAM PASS THROUGH PASS THROUGH PASS THROUGH CHARGES CHARGES COSTS COSTS COSTS 8.01 8.02 9 9.01 9.02
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ROUTINE SERVICE CAPITAL COSTS WORKSHEET D PART I
CHECK [ ] TITLE V APPLICABLE [ ] TITLE XVIII-PT ABOXES [XX] TITLE XIX ---------- OLD CAPITAL ---------- ---------- NEW CAPITAL ---------- REDUCED REDUCED CAPITAL SWING-BED CAPITAL CAPITAL SWING-BED CAPITAL COST CENTER DESCRIPTION RELATED ADJUSTMENT RELATED RELATED ADJUSTMENT RELATED COST COST COST COST 1 2 3 4 5 6
INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 2890303 2890303 25 26 INTENSIVE CARE UNIT 458172 458172 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 29.01 NEONATAL INTENSIVE CARE 554024 554024 29.01 29.02 PEDIATRIC INTENSIVE CARE 117484 117484 29.02 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 170539 170539 31 33 NURSERY 102328 102328 33 101 TOTAL 4292850 4292850 101
---- OLD CAPITAL ---- ---- NEW CAPITAL ---- INPATIENT INPATIENT TOTAL INPATIENT PER PROGRAM PER PROGRAM COST CENTER DESCRIPTION PATIENT PROGRAM DIEM CAPITAL DIEM CAPITAL DAYS DAYS COST COST 7 8 9 10 11 12
INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 55150 11042 52.41 578711 25 26 INTENSIVE CARE UNIT 5794 384 79.08 30367 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 29.01 NEONATAL INTENSIVE CARE 12208 5916 45.38 268468 29.01 29.02 PEDIATRIC INTENSIVE CARE 908 464 129.39 60037 29.02 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 2958 842 57.65 48541 31 33 NURSERY 3863 3776 26.49 100026 33 101 TOTAL 80881 22424 1086150 101
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS WORKSHEET D PART II
CHECK [ ] TITLE V [XX] HOSPITAL (14-0239) [ ] SUB III [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SUB IV [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [XX] OTHER
OLD NEW ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- CAPITAL CAPITAL INPATIENT RATIO OF RATIO OF COST CENTER DESCRIPTION RELATED RELATED TOTAL PROGRAM COST TO CAPITAL COST TO CAPITAL COST COST CHARGES CHARGES CHARGES COSTS CHARGES COSTS 1 2 3 4 5 6 7 8
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART III
CHECK [ ] TITLE V APPLICABLE [ ] TITLE XVIII-PT ABOXES [XX] TITLE XIX ALL OTHER NONPHYSICIAN NURSING ALLIED MEDICAL SWING-BED COST CENTER DESCRIPTION ANESTHETIST SCHOOL HEALTH EDUCATION ADJUSTMENT TOTAL COST COST COSTS COSTS AMOUNT COSTS 1 2 2.01 2.02 3 4
INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 102177 102177 25 26 INTENSIVE CARE UNIT 62957 62957 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 29.01 NEONATAL INTENSIVE CARE 18490 18490 29.01 29.02 PEDIATRIC INTENSIVE CARE 1703 1703 29.02 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 3915 3915 31 33 NURSERY 5588 5588 33 34 SKILLED NURSING FACILITY 34 35 NURSING FACILITY 35 101 TOTAL 194830 194830 101
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ROUTINE SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART III
CHECK [ ] TITLE V APPLICABLE [ ] TITLE XVIII-PT ABOXES [XX] TITLE XIX INPATIENT TOTAL INPATIENT PROGRAM COST CENTER DESCRIPTION PATIENT PER PROGRAM PASS THRU DAYS DIEM DAYS COSTS 5 6 7 8
INPAT ROUTINE SERV COST CTRS 25 ADULTS & PEDIATRICS 55150 1.85 11042 20428 25 26 INTENSIVE CARE UNIT 5794 10.87 384 4174 26 27 CORONARY CARE UNIT 27 28 BURN INTENSIVE CARE UNIT 28 29 SURGICAL INTENSIVE CARE UNIT 29 29.01 NEONATAL INTENSIVE CARE 12208 1.51 5916 8933 29.01 29.02 PEDIATRIC INTENSIVE CARE 908 1.88 464 872 29.02 30 OTHER SPECIAL CARE (SPECIFY) 30 31 SUBPROVIDER I 2958 1.32 842 1111 31 33 NURSERY 3863 1.45 3776 5475 33 34 SKILLED NURSING FACILITY 34 35 NURSING FACILITY 35 101 TOTAL 80881 22424 40993 101
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [XX] HOSPITAL (14-0239) [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR
OUTPATIENT ALL OTHER NONPHYSICIAN NONPHYSICIAN NURSING ALLIED MEDICAL ADMINISTERING COST CENTER DESCRIPTION ANESTHETIST ANESTHETIST SCHOOL HEALTH EDUCATION BLOOD CLOTTING TOTAL COST COST COST COSTS COSTS FACTORS COST COSTS 1 1.01 2 2.01 2.02 2.03 3
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [XX] HOSPITAL (14-0239) [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR
INPATIENT OUTPATIENT RATIO OF OUTPATIENT INPATIENT PROGRAM OUTPATIENT COST CENTER DESCRIPTION PASS THROUGH TOTAL COST TO RATIO OF COST PROGRAM PASS THROUGH PROGRAM COSTS CHARGES CHARGES TO CHARGES CHARGES COSTS CHARGES 3.01 4 5 5.01 6 7 8
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [XX] HOSPITAL (14-0239) [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [ ] SUB I [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR
OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT PROGRAM PROGRAM PROGRAM COST CENTER DESCRIPTION PROGRAM PROGRAM PASS THROUGH PASS THROUGH PASS THROUGH CHARGES CHARGES COSTS COSTS COSTS 8.01 8.02 9 9.01 9.02
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS WORKSHEET D PART II
CHECK [ ] TITLE V [ ] HOSPITAL [ ] SUB III [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [XX] SUB I (14-S239) [ ] SUB IV [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [XX] OTHER
OLD NEW ---- OLD CAPITAL ---- ---- NEW CAPITAL ---- CAPITAL CAPITAL INPATIENT RATIO OF RATIO OF COST CENTER DESCRIPTION RELATED RELATED TOTAL PROGRAM COST TO CAPITAL COST TO CAPITAL COST COST CHARGES CHARGES CHARGES COSTS CHARGES COSTS 1 2 3 4 5 6 7 8
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [ ] HOSPITAL [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [XX] SUB I (14-S239) [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR
OUTPATIENT ALL OTHER NONPHYSICIAN NONPHYSICIAN NURSING ALLIED MEDICAL ADMINISTERING COST CENTER DESCRIPTION ANESTHETIST ANESTHETIST SCHOOL HEALTH EDUCATION BLOOD CLOTTING TOTAL COST COST COST COSTS COSTS FACTORS COST COSTS 1 1.01 2 2.01 2.02 2.03 3
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [ ] HOSPITAL [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [XX] SUB I (14-S239) [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR
INPATIENT OUTPATIENT RATIO OF OUTPATIENT INPATIENT PROGRAM OUTPATIENT COST CENTER DESCRIPTION PASS THROUGH TOTAL COST TO RATIO OF COST PROGRAM PASS THROUGH PROGRAM COSTS CHARGES CHARGES TO CHARGES CHARGES COSTS CHARGES 3.01 4 5 5.01 6 7 8
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 APPORTIONMENT OF INPATIENT ANCILLARY SERVICE OTHER PASS THROUGH COSTS WORKSHEET D PART IV
CHECK [ ] TITLE V [ ] HOSPITAL [ ] SUB IV [ ] PPS APPLICABLE [ ] TITLE XVIII-PT A [XX] SUB I (14-S239) [ ] SNF [ ] TEFRA BOXES [XX] TITLE XIX [ ] SUB II [ ] NF [ ] OTHER [ ] SUB III [ ] ICF/MR
OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT OUTPATIENT PROGRAM PROGRAM PROGRAM COST CENTER DESCRIPTION PROGRAM PROGRAM PASS THROUGH PASS THROUGH PASS THROUGH CHARGES CHARGES COSTS COSTS COSTS 8.01 8.02 9 9.01 9.02
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT
PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV SNF (PPS) (PPS) (14-0239)(14-S239) INPATIENT DAYS 1 1 1 1 1 1
1 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS AND SWING-BED DAYS 55150 2958 1 EXCLUDING NEWBORN) 2 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS, EXCLUDING SWING 55150 2958 2 BED AND NEWBORN DAYS) 3 PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 41757 3 4 SEMI-PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 13393 2958 4 5 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 5 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 6 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 6 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 7 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 7 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 8 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 8 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 9 INPATIENT DAYS INCLUDING PRIVATE ROOM DAYS APPLICABLE TO THE 23893 711 9 PROGRAM (EXCLUDING SWING-BED AND NEWBORN DAYS) 10 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 10 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 11 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 11 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 12 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 12 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 13 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 13 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 14 MEDICALLY NECESSARY PRIVATE ROOM DAYS APPLICABLE TO THE 14 PROGRAM (EXCLUDING SWING-BED DAYS) 15 TOTAL NURSERY DAYS 1516 TITLE V OR XIX NURSERY DAYS 16
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I (CONT) [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT
PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV SNF (PPS) (PPS) (14-0239)(14-S239) SWING-BED ADJUSTMENT 1 1 1 1 1 1
17 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 17 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 18 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 613.53 18 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 19 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 19 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 20 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 215.15 20 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 21 TOTAL GENERAL INPATIENT ROUTINE SERVICE COST 51482606 2731519 2122 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES THROUGH 22 DECEMBER 31 OF THE COST REPORTING PERIOD 23 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES AFTER 23 DECEMBER 31 OF THE COST REPORTING PERIOD 24 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES THROUGH 24 DECEMBER 31 OF THE COST REPORTING PERIOD 25 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES AFTER 25 DECEMBER 31 OF THE COST REPORTING PERIOD 26 TOTAL SWING-BED COST 2627 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 51482606 2731519 27
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28 GENERAL INPATIENT ROUTINE SERVICE CHARGES 55676659 3055947 28 (EXCLUDING SWING-BED CHARGES) 29 PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 2930 SEMI-PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 55676659 3055947 3031 GENERAL INPATIENT ROUTINE SERVICE COST/CHARGE RATIO .924671 .893837 3132 AVERAGE PRIVATE ROOM PER DIEM CHARGE 3233 AVERAGE SEMI-PRIVATE ROOM PER DIEM CHARGE 4157.15 1033.11 3334 AVERAGE PER DIEM PRIVATE ROOM CHARGE DIFFERENTIAL 3435 AVERAGE PER DIEM PRIVATE ROOM COST DIFFERENTIAL 3536 PRIVATE ROOM COST DIFFERENTIAL ADJUSTMENT 3637 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 51482606 2731519 37 AND PRIVATE ROOM COST DIFFERENTIAL
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT
PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (PPS) (14-0239)(14-S239) PROGRAM INPATIENT OPERATING COST BEFORE 1 1 1 1 1 PASS THROUGH COST ADJUSTMENTS
38 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 933.50 923.43 3839 PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 22304116 656559 3940 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO THE PROGRAM 4041 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 22304116 656559 41
TOTAL TOTAL AVERAGE PROGRAM PROGRAM I/P COST I/P DAYS PER DIEM DAYS COST 1 2 3 4 5
42 NURSERY (TITLES V AND XIX ONLY) 42 INTENSIVE CARE TYPE INPATIENT HOSPITAL UNITS 43 INTENSIVE CARE UNIT 10838062 5794 1870.57 3245 6070000 43 44 CORONARY CARE UNIT 44 45 BURN INTENSIVE CARE UNIT 45 46 SURGICAL INTENSIVE CARE UNIT 46 46.01 NEONATAL INTENSIVE CARE 13025601 12208 1066.97 46.0146.02 PEDIATRIC INTENSIVE CARE 1840170 908 2026.62 46.0247 OTHER SPECIAL CARE (SPECIFY) 47
HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (PPS) (14-0239)(14-S239) 1 1 1 1 1
48 PROGRAM INPATIENT ANCILLARY SERVICE COST 41253416 117183 4849 TOTAL PROGRAM INPATIENT COSTS 69627532 773742 49
PASS THROUGH COST ADJUSTMENTS
50 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ROUTINE 1588322 41928 50 SERVICES 51 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT 3183599 9041 51 ANCILLARY SERVICES 52 TOTAL PROGRAM EXCLUDABLE COST 4771921 50969 5253 TOTAL PROGRAM INPATIENT OPERATING COST EXCLUDING CAPITAL 64855611 722773 53 RELATED, NONPHYSICIAN ANESTHETIST AND MEDICAL EDUCATION COSTS
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II (CONT) [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT
PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (PPS) (14-0239)(14-S239) TARGET AMOUNT AND LIMITATION COMPUTATION 1 1 1 1 154 PROGRAM DISCHARGES 5455 TARGET AMOUNT PER DISCHARGE 5556 TARGET AMOUNT 5657 DIFFERENCE BETWEEN ADJUSTED INPATIENT OPERATING COST AND 57 TARGET AMOUNT 58 BONUS PAYMENT 5858.01 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM THE COST REPORTING 58.01 PERIOD ENDING 1996, UPDATED & COMPOUNDED BY THE MARKET BASKET 58.02 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM PRIOR YEAR COST 58.02 REPORT UPDATED BY THE MARKET BASKET 58.03 IF LINE 53/LINE 54 IS LESS THAN THE LOWER OF LINES 55, 58.01 58.03 OR 58.02, THE LESSER OF 50% OF THE AMOUNT BY WHICH OPERATING COSTS ARE LESS THAN EXPECTED COSTS, OR 1% OF THE TARGET AMOUNT58.04 RELIEF PAYMENT 58.0459 ALLOWABLE INPATIENT COST PLUS INCENTIVE PAYMENT 5959.01 ALLOWABLE INPATIENT COST PER DISCHARGE (LTCH ONLY) 59.0159.02 PROGRAM DISCHARGES PRIOR TO JULY 1 59.0259.03 PROGRAM DISCHARGES AFTER JULY 1 59.0359.04 PROGRAM DISCHARGES (SEE INSTRUCTIONS) 59.0459.05 REDUCED INPAT COST PER DISCH. FOR DISCHARGES PRIOR TO JULY 1 59.0559.06 REDUCED INPAT COST PER DISCHARGE FOR DISCHARGES AFTER JULY 1 59.0659.07 REDUCED INPAT COST PER DISCHARGE (SEE INSTR.) (LTCH ONLY) 59.0759.08 REDUCED INPATIENT COST PLUS INCENTIVE PAYMENT (SEE INSTR.) 59.08
PROGRAM INPATIENT ROUTINE SWING BED COST
60 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS THROUGH 60 DECEMBER 31 OF THE COST REPORTING PERIOD 61 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS AFTER 61 DECEMBER 31 OF THE COST REPORTING PERIOD 62 TOTAL MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS 6263 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS THROUGH 63 DECEMBER 31 OF THE COST REPORTING PERIOD 64 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS AFTER 64 DECEMBER 31 OF THE COST REPORTING PERIOD 65 TOTAL TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS 65
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT
PART III - SKILLED NURSING FACILITY, NURSING FACILITY AND ICF/MR ONLY SNF 166 SNF/NF/ICF/MR ROUTINE SERVICE COST 6667 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 6768 PROGRAM ROUTINE SERVICE COST 6869 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO PROGRAM 6970 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COSTS 7071 CAPITAL RELATED COST ALLOCATED TO INPATIENT ROUTINE SERV COSTS 7172 PER DIEM CAPITAL RELATED COSTS 7273 PROGRAM CAPITAL RELATED COSTS 7374 INPATIENT ROUTINE SERVICE COST 7475 AGGREGATE CHARGES TO BENEFICIARIES FOR EXCESS COSTS 7576 TOTAL PGM ROUTINE SERVICE COSTS FOR COMPARISON TO COST LIMIT 7677 INPATIENT ROUTINE SERVICE COST PER DIEM LIMITATION 7778 INPATIENT ROUTINE SERVICE COST LIMITATION 7879 REASONABLE INPATIENT ROUTINE SERVICE COSTS 7980 PROGRAM INPATIENT ANCILLARY SERVICES 8081 UTILIZATION REVIEW--PHYSICIAN COMPENSATION 8182 TOTAL PROGRAM INPATIENT OPERATING COSTS 82
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [XX] TITLE XVIII-PART A [ ] TITLE XIX-INPT
HOSPITAL SUB I SUB II SUB III SUB IV (PPS) (PPS) (14-0239)(14-S239) 1 1 1 1 1PART IV - COMPUTATION OF OBSERVATION BED COST
83 TOTAL OBSERVATION BEDS 2998 8384 ADJUSTED GENERAL INPATIENT ROUTINE COST PER DIEM 933.50 8485 OBSERVATION BED COST 2798633 85
COMPUTATION OF OBSERVATION BED PASS THROUGH COST - HOSPITAL TOTAL ROUTINE COLUMN 1 OBSERVATION OBSERVATION BED COST DIVIDED BY BED COST PASS-THROUGH COST COST (FROM LINE 27) COLUMN 2 (FROM LINE 85) COL 3 TIMES COL 4 1 2 3 4 5
86 OLD CAPITAL-RELATED COST 51482606 2798633 8687 NEW CAPITAL-RELATED COST 2890303 51482606 .056141 2798633 157118 8788 NON PHYSICIAN ANESTHETIST 51482606 2798633 8889 NURSING SCHOOL 51482606 2798633 8989.01 ALLIED HEALTH 102177 51482606 .001985 2798633 5555 89.0189.02 ALL OTHER 51482606 2798633 89.02
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT
PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV NF (OTHER) (OTHER) (14-0239)(14-S239) INPATIENT DAYS 1 1 1 1 1 1
1 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS AND SWING-BED DAYS 55150 2958 1 EXCLUDING NEWBORN) 2 INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS, EXCLUDING SWING 55150 2958 2 BED AND NEWBORN DAYS) 3 PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 41757 3 4 SEMI-PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 13393 2958 4 5 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 5 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 6 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE 6 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 7 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 7 ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 8 TOTAL SWING-BED NF-TYPE INPATIENT DAYS (INCL PRIVATE 8 ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 9 INPATIENT DAYS INCLUDING PRIVATE ROOM DAYS APPLICABLE TO THE 11042 842 9 PROGRAM (EXCLUDING SWING-BED AND NEWBORN DAYS) 10 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 10 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 11 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII 11 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 12 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 12 ONLY (INCLUDING PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 13 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V OR XIX 13 ONLY (INCLUDING PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 14 MEDICALLY NECESSARY PRIVATE ROOM DAYS APPLICABLE TO THE 14 PROGRAM (EXCLUDING SWING-BED DAYS) 15 TOTAL NURSERY DAYS 3863 1516 TITLE V OR XIX NURSERY DAYS 3776 16
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART I (CONT) [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT
PART I - ALL PROVIDER COMPONENTS HOSPITAL SUB I SUB II SUB III SUB IV NF (OTHER) (OTHER) (14-0239)(14-S239) SWING-BED ADJUSTMENT 1 1 1 1 1 1
17 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 17 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 18 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO 613.53 18 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 19 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 19 SERVICES THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD 20 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO 215.15 20 SERVICES AFTER DECEMBER 31 OF THE COST REPORTING PERIOD 21 TOTAL GENERAL INPATIENT ROUTINE SERVICE COST 51482606 2731519 2122 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES THROUGH 22 DECEMBER 31 OF THE COST REPORTING PERIOD 23 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES AFTER 23 DECEMBER 31 OF THE COST REPORTING PERIOD 24 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES THROUGH 24 DECEMBER 31 OF THE COST REPORTING PERIOD 25 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES AFTER 25 DECEMBER 31 OF THE COST REPORTING PERIOD 26 TOTAL SWING-BED COST 2627 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 51482606 2731519 27
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28 GENERAL INPATIENT ROUTINE SERVICE CHARGES 55676659 3055947 28 (EXCLUDING SWING-BED CHARGES) 29 PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 2930 SEMI-PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 55676659 3055947 3031 GENERAL INPATIENT ROUTINE SERVICE COST/CHARGE RATIO .924671 .893837 3132 AVERAGE PRIVATE ROOM PER DIEM CHARGE 3233 AVERAGE SEMI-PRIVATE ROOM PER DIEM CHARGE 4157.15 1033.11 3334 AVERAGE PER DIEM PRIVATE ROOM CHARGE DIFFERENTIAL 3435 AVERAGE PER DIEM PRIVATE ROOM COST DIFFERENTIAL 3536 PRIVATE ROOM COST DIFFERENTIAL ADJUSTMENT 3637 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 51482606 2731519 37 AND PRIVATE ROOM COST DIFFERENTIAL
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT
PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (OTHER) (OTHER) (14-0239)(14-S239) PROGRAM INPATIENT OPERATING COST BEFORE 1 1 1 1 1 PASS THROUGH COST ADJUSTMENTS
38 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 933.50 923.43 3839 PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 10307707 777528 3940 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO THE PROGRAM 4041 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 10307707 777528 41
TOTAL TOTAL AVERAGE PROGRAM PROGRAM I/P COST I/P DAYS PER DIEM DAYS COST 1 2 3 4 5
42 NURSERY (TITLES V AND XIX ONLY) 2742231 3863 709.87 3776 2680469 42 INTENSIVE CARE TYPE INPATIENT HOSPITAL UNITS 43 INTENSIVE CARE UNIT 10822483 5794 1867.88 384 717266 43 44 CORONARY CARE UNIT 44 45 BURN INTENSIVE CARE UNIT 45 46 SURGICAL INTENSIVE CARE UNIT 46 46.01 NEONATAL INTENSIVE CARE 13009881 12208 1065.68 5916 6304563 46.0146.02 PEDIATRIC INTENSIVE CARE 1840170 908 2026.62 464 940352 46.0247 OTHER SPECIAL CARE (SPECIFY) 47
HOSPITAL SUB I SUB II SUB III SUB IV (OTHER) (OTHER) (14-0239)(14-S239) 1 1 1 1 1
48 PROGRAM INPATIENT ANCILLARY SERVICE COST 4849 TOTAL PROGRAM INPATIENT COSTS 20950357 777528 49
PASS THROUGH COST ADJUSTMENTS
50 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ROUTINE 1077491 49652 50 SERVICES 51 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT 51 ANCILLARY SERVICES 52 TOTAL PROGRAM EXCLUDABLE COST 1077491 49652 5253 TOTAL PROGRAM INPATIENT OPERATING COST EXCLUDING CAPITAL 53 RELATED, NONPHYSICIAN ANESTHETIST AND MEDICAL EDUCATION COSTS
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PART II (CONT) [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT
PART II - HOSPITAL AND SUBPROVIDERS ONLY HOSPITAL SUB I SUB II SUB III SUB IV (OTHER) (OTHER) (14-0239)(14-S239) TARGET AMOUNT AND LIMITATION COMPUTATION 1 1 1 1 154 PROGRAM DISCHARGES 182 5455 TARGET AMOUNT PER DISCHARGE 5556 TARGET AMOUNT 5657 DIFFERENCE BETWEEN ADJUSTED INPATIENT OPERATING COST AND 57 TARGET AMOUNT 58 BONUS PAYMENT 5858.01 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM THE COST REPORTING 58.01 PERIOD ENDING 1996, UPDATED & COMPOUNDED BY THE MARKET BASKET 58.02 LESSER OF LINE 53/LINE 54 OR LINE 55 FROM PRIOR YEAR COST 58.02 REPORT UPDATED BY THE MARKET BASKET 58.03 IF LINE 53/LINE 54 IS LESS THAN THE LOWER OF LINES 55, 58.01 58.03 OR 58.02, THE LESSER OF 50% OF THE AMOUNT BY WHICH OPERATING COSTS ARE LESS THAN EXPECTED COSTS, OR 1% OF THE TARGET AMOUNT58.04 RELIEF PAYMENT 58.0459 ALLOWABLE INPATIENT COST PLUS INCENTIVE PAYMENT 5959.01 ALLOWABLE INPATIENT COST PER DISCHARGE (LTCH ONLY) 59.0159.02 PROGRAM DISCHARGES PRIOR TO JULY 1 59.0259.03 PROGRAM DISCHARGES AFTER JULY 1 59.0359.04 PROGRAM DISCHARGES (SEE INSTRUCTIONS) 59.0459.05 REDUCED INPAT COST PER DISCH. FOR DISCHARGES PRIOR TO JULY 1 59.0559.06 REDUCED INPAT COST PER DISCHARGE FOR DISCHARGES AFTER JULY 1 59.0659.07 REDUCED INPAT COST PER DISCHARGE (SEE INSTR.) (LTCH ONLY) 59.0759.08 REDUCED INPATIENT COST PLUS INCENTIVE PAYMENT (SEE INSTR.) 59.08
PROGRAM INPATIENT ROUTINE SWING BED COST
60 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS THROUGH 60 DECEMBER 31 OF THE COST REPORTING PERIOD 61 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS AFTER 61 DECEMBER 31 OF THE COST REPORTING PERIOD 62 TOTAL MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS 6263 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS THROUGH 63 DECEMBER 31 OF THE COST REPORTING PERIOD 64 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS AFTER 64 DECEMBER 31 OF THE COST REPORTING PERIOD 65 TOTAL TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS 65
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT
PART III - SKILLED NURSING FACILITY, NURSING FACILITY AND ICF/MR ONLY NF 166 SNF/NF/ICF/MR ROUTINE SERVICE COST 6667 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 6768 PROGRAM ROUTINE SERVICE COST 6869 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO PROGRAM 6970 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COSTS 7071 CAPITAL RELATED COST ALLOCATED TO INPATIENT ROUTINE SERV COSTS 7172 PER DIEM CAPITAL RELATED COSTS 7273 PROGRAM CAPITAL RELATED COSTS 7374 INPATIENT ROUTINE SERVICE COST 7475 AGGREGATE CHARGES TO BENEFICIARIES FOR EXCESS COSTS 7576 TOTAL PGM ROUTINE SERVICE COSTS FOR COMPARISON TO COST LIMIT 7677 INPATIENT ROUTINE SERVICE COST PER DIEM LIMITATION 7778 INPATIENT ROUTINE SERVICE COST LIMITATION 7879 REASONABLE INPATIENT ROUTINE SERVICE COSTS 7980 PROGRAM INPATIENT ANCILLARY SERVICES 8081 UTILIZATION REVIEW--PHYSICIAN COMPENSATION 8182 TOTAL PROGRAM INPATIENT OPERATING COSTS 82
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 COMPUTATION OF INPATIENT OPERATING COST WORKSHEET D-1 PARTS III & IV [ ] TITLE V-INPT [ ] TITLE XVIII-PART A [XX] TITLE XIX-INPT
HOSPITAL SUB I SUB II SUB III SUB IV (OTHER) (OTHER) (14-0239)(14-S239) 1 1 1 1 1PART IV - COMPUTATION OF OBSERVATION BED COST
83 TOTAL OBSERVATION BEDS 2998 8384 ADJUSTED GENERAL INPATIENT ROUTINE COST PER DIEM 933.50 8485 OBSERVATION BED COST 2798633 85
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 INPATIENT ANCILLARY COST APPORTIONMENT WORKSHEET D-4
[ ] TITLE V [XX] HOSPITAL (14-0239) [ ] SNF [XX] PPS[XX] TITLE XVIII-PT A [ ] SUB I [ ] NF [ ] TEFRA[ ] TITLE XIX [ ] SUB II [ ] S/B-SNF [ ] OTHER [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR
RATIO OF COST INPATIENT INPATIENT COST CENTER DESCRIPTION TO CHARGES PROGRAM CHARGES PROGRAM COSTS 1 2 3
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 INPATIENT ANCILLARY COST APPORTIONMENT WORKSHEET D-4
[ ] TITLE V [ ] HOSPITAL [ ] SNF [XX] PPS[XX] TITLE XVIII-PT A [XX] SUB I (14-S239) [ ] NF [ ] TEFRA[ ] TITLE XIX [ ] SUB II [ ] S/B-SNF [ ] OTHER [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR
RATIO OF COST INPATIENT INPATIENT COST CENTER DESCRIPTION TO CHARGES PROGRAM CHARGES PROGRAM COSTS 1 2 3
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 INPATIENT ANCILLARY COST APPORTIONMENT WORKSHEET D-4
[ ] TITLE V [XX] HOSPITAL (14-0239) [ ] SNF [ ] PPS[ ] TITLE XVIII-PT A [ ] SUB I [ ] NF [ ] TEFRA[XX] TITLE XIX [ ] SUB II [ ] S/B-SNF [XX] OTHER [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR
RATIO OF COST INPATIENT INPATIENT COST CENTER DESCRIPTION TO CHARGES PROGRAM CHARGES PROGRAM COSTS 1 2 3
INPATIENT ROUTINE SERVICE COST CENTERS 25 ADULTS & PEDIATRICS 25 26 INTENSIVE CARE UNIT 26 29.01 NEONATAL INTENSIVE CARE 29.01 29.02 PEDIATRIC INTENSIVE CARE 29.02 31 SUBPROVIDER I 31 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM .336421 37 38 RECOVERY ROOM .329571 38 39 DELIVERY ROOM & LABOR ROOM .593539 39 40 ANESTHESIOLOGY .342489 40 41 RADIOLOGY-DIAGNOSTIC .235234 41 42 RADIOLOGY-THERAPEUTIC .417281 42 43 RADIOISOTOPE .272528 43 44 LABORATORY .283831 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA .249847 47 49 RESPIRATORY THERAPY .242771 49 50 PHYSICAL THERAPY .601329 50 53 ELECTROCARDIOLOGY .127772 53 54 ELECTROENCEPHALOGRAPHY .216784 54 55 MEDICAL SUPPLIES CHARGED TO PAT .277293 55 56 DRUGS CHARGED TO PATIENTS .326378 56 57 RENAL DIALYSIS .489825 57 59 GI LAB .267005 59 59.01 MRI .120486 59.01 59.02 CT SCAN .063090 59.02 59.03 CARDIAC CATHETERIZATION .288017 59.03 59.04 PRIMARY PREVENTION PROGRAM 59.04 59.05 WOMEN'S HEALTH ADVANTAGE 4.271081 59.05 59.07 OUTPATIENT DETOX 59.07 59.08 SPECIAL SURGICAL SERVICES .360918 59.08 59.10 GENETIC SERVICES 1.246533 59.10 59.11 CARDIOLOGY 59.11 59.12 OUTPATIENT PSYCH SERVICES 59.12 OUTPATIENT SERVICE COST CENTERS 60.01 PAIN CENTER .230472 60.01 60.02 ANTENATAL TEST CENTER .240490 60.02 60.03 CHILD PSYCHIATRIC CLINIC 2.379864 60.03 61 EMERGENCY .360108 61 62 OBSERVATION BEDS (NON-DISTINCT .974492 62 OTHER REIMBURSABLE COST CENTERS 63.50 RHC 63.50 63.60 FQHC 63.60 65 AMBULANCE SERVICES 65 68 AIR AMBULANCE 68 101 TOTAL 101102 LESS PBP CLINIC LAB SVCS-PGM ONLY CHARGES 102103 NET CHARGES 103
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 INPATIENT ANCILLARY COST APPORTIONMENT WORKSHEET D-4
[ ] TITLE V [ ] HOSPITAL [ ] SNF [ ] PPS[ ] TITLE XVIII-PT A [XX] SUB I (14-S239) [ ] NF [ ] TEFRA[XX] TITLE XIX [ ] SUB II [ ] S/B-SNF [XX] OTHER [ ] SUB III [ ] S/B-NF [ ] SUB IV [ ] ICF/MR
RATIO OF COST INPATIENT INPATIENT COST CENTER DESCRIPTION TO CHARGES PROGRAM CHARGES PROGRAM COSTS 1 2 3
INPATIENT ROUTINE SERVICE COST CENTERS 25 ADULTS & PEDIATRICS 25 26 INTENSIVE CARE UNIT 26 29.01 NEONATAL INTENSIVE CARE 29.01 29.02 PEDIATRIC INTENSIVE CARE 29.02 31 SUBPROVIDER I 31 ANCILLARY SERVICE COST CENTERS 37 OPERATING ROOM .336421 37 38 RECOVERY ROOM .329571 38 39 DELIVERY ROOM & LABOR ROOM .593539 39 40 ANESTHESIOLOGY .342489 40 41 RADIOLOGY-DIAGNOSTIC .235234 41 42 RADIOLOGY-THERAPEUTIC .417281 42 43 RADIOISOTOPE .272528 43 44 LABORATORY .283831 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.30 47 BLOOD STORING, PROCESSING & TRA .249847 47 49 RESPIRATORY THERAPY .242771 49 50 PHYSICAL THERAPY .601329 50 53 ELECTROCARDIOLOGY .127772 53 54 ELECTROENCEPHALOGRAPHY .216784 54 55 MEDICAL SUPPLIES CHARGED TO PAT .277293 55 56 DRUGS CHARGED TO PATIENTS .326378 56 57 RENAL DIALYSIS .489825 57 59 GI LAB .267005 59 59.01 MRI .120486 59.01 59.02 CT SCAN .063090 59.02 59.03 CARDIAC CATHETERIZATION .288017 59.03 59.04 PRIMARY PREVENTION PROGRAM 59.04 59.05 WOMEN'S HEALTH ADVANTAGE 4.271081 59.05 59.07 OUTPATIENT DETOX 59.07 59.08 SPECIAL SURGICAL SERVICES .360918 59.08 59.10 GENETIC SERVICES 1.246533 59.10 59.11 CARDIOLOGY 59.11 59.12 OUTPATIENT PSYCH SERVICES 59.12 OUTPATIENT SERVICE COST CENTERS 60.01 PAIN CENTER .230472 60.01 60.02 ANTENATAL TEST CENTER .240490 60.02 60.03 CHILD PSYCHIATRIC CLINIC 2.379864 60.03 61 EMERGENCY .360108 61 62 OBSERVATION BEDS (NON-DISTINCT .974492 62 OTHER REIMBURSABLE COST CENTERS 63.50 RHC 63.50 63.60 FQHC 63.60 65 AMBULANCE SERVICES 65 68 AIR AMBULANCE 68 101 TOTAL 101102 LESS PBP CLINIC LAB SVCS-PGM ONLY CHARGES 102103 NET CHARGES 103
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART A PART A - INPATIENT HOSPITAL SERVICES UNDER PPS HOSPITAL SUB I SUB II SUB III SUB IV (14-0239) DRG AMOUNT 1 OTHER THAN OUTLIER PAYMENTS OCCURRING BEFORE OCTOBER 1 30083961 1 1.01 OTHER THAN OUTLIER PAYMENTS OCCURRING ON OR AFTER 9662318 1.01 OCTOBER 1 AND BEFORE JANUARY 1 1.02 OTHER THAN OUTLIER PAYMENTS OCCURRING ON OR AFTER JAN 1 1.02 MANAGED CARE PATIENTS 1.03 PAYMENTS PRIOR TO MARCH 1 OR OCTOBER 1 1.03 1.04 PAYMENTS ON OR AFTER OCTOBER 1 AND PRIOR TO JANUARY 1 1.04 1.05 PAYMENTS ON OR AFTER JAN 1 BUT BEFORE APR 1/OCT 1 1.05 1.06 ADDITIONAL AMOUNT RECEIVED OR TO BE RECEIVED 1.06 1.07 PAYMENTS FOR DISCHARGES ON OR AFTER APRIL 1, 2001 1.07 THROUGH SEPTEMBER 30, 2001 1.08 SIMULATED PAYMENTS FROM THE PS&R ON OR AFTER 1.08 APRIL 1, 2001 THROUGH SEPTEMBER 30, 2001 2 OUTLIER PAYMENTS PRIOR TO OCTOBER 1, 1997 2 2.01 OUTLIER PAYMENTS ON OR AFTER OCTOBER 1, 1997 4156974 2.01 INDIRECT MEDICAL EDUCATION ADJUSTMENT 3 BED DAYS AVAILABLE DIVIDED BY NO. OF DAYS IN CR PERIOD 276.77 3 3.01 NO OF INTERNS & RESIDENTS FROM WORKSHEET S-3, PART I 3.01 3.02 INDIRECT MEDICAL EDUCATION PERCENTAGE 3.02 3.03 INDIRECT MEDICAL EDUCATION ADJUSTMENT 3.03 3.04 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PGMS FOR THE 3.04 MOST RECENT CR PERIOD ENDING ON OR BEFORE DEC 31, 1996 3.05 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PGMS WHICH 3.05 MEET THE CRITERIA FOR AN ADD-ON TO THE CAP FOR NEW PROGRAMS IN ACCORDANCE WITH SECTION 1886(d)(5)(B)(viii) 3.06 ADJUSTED FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PGMS 3.06 FOR AFFILIATED PROGRAMS IN ACCORDANCE WITH SECTION 1886(d)(5)(B)(viii) [ FOR CR PERIODS ENDING ] [ ON OR AFTER 7/1/2005 ] [E-3,PT.VI,LN.15][PLUS LN.3.06] 3.07 SUM OF LINES 3.04-3.06 0.00 0.00 3.07 3.08 FTE COUNT FOR ALLOPATHIC AND OSTEOPATHIC PROGRAMS IN 3.08 THE CURRENT YEAR FROM YOUR RECORDS 3.09 FOR CR PERIODS BEGINNING BEFORE OCTOBER 1, ENTER THE 3.09 PERCENTAGE OF DISCHARGES OCCURRING PRIOR TO OCTOBER 1 3.10 FOR CR PERIODS BEGINNING BEFORE OCTOBER 1, ENTER THE 3.10 PERCENTAGE OF DISCHARGES OCCURRING ON OR AFTER OCT. 1 3.11 FTE COUNT FOR THE PERIOD IDENTIFIED IN LINE 3.09 3.11 3.12 FTE COUNT FOR THE PERIOD IDENTIFIED IN LINE 3.10 3.12 3.13 FTE COUNT FOR RESIDENTS IN DENTAL & PODIATRIC PROGRAMS 3.13 3.14 CURRENT YEAR ALLOWABLE FTE 3.14 3.15 TOTAL ALLOWABLE FTE COUNT FOR THE PRIOR YEAR, IF NONE 3.15 BUT PRIOR YEAR TEACHING WAS IN EFFECT ENTER 1 HERE.. 3.16 TOTAL ALLOWABLE FTE COUNT FOR THE PENULTIMATE YEAR IF 3.16 THAT YEAR ENDED ON OR AFTER SEPTEMBER 30, 1997, OTHERWISE ENTER ZERO. IF THERE WAS NO FTE COUNT IN THIS PERIOD BUT PRIOR YR TEACHING WAS IN EFFECT ENTER 1 HERE.. RES. IN INIT YRS 3.17 SUM OF LINES 3.14 THROUGH 3.16 DIVIDED BY THE 0.00 3.17 NUMBER OF THOSE LINES IN EXCESS OF ZERO
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART A PART A - INPATIENT HOSPITAL SERVICES UNDER PPS (CONT)
HOSPITAL SUB I SUB II SUB III SUB IV (14-0239)
3.18 CURRENT YEAR RESIDENT TO BED RATIO 3.18 3.19 PRIOR YEAR RESIDENT TO BED RATIO 3.19 3.20 FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 3.20 OCTOBER 1, 1997, ENTER THE LESSER OF LINES 3.18 OR 3.19 3.21 IME PAYMENTS FOR DSCHGS OCCURRING PRIOR TO OCTOBER 1 3.21 3.22 IME PAYMENTS FOR DSCHGS AFTER SEP 30 BUT BEFORE JAN 1 3.22 3.23 IME PAYMENTS FOR DSCHGS OCCURRING ON OR AFTER JANUARY 1 3.23 [SUM OF LINES][PLUS E-3,PT.VI] [ 3.21-3.23 ][ LINE 23 ] 3.24 SUM OF LINES 3.21-3.23 0 0 3.24 DISPROPORTIONATE SHARE ADJUSTMENT 4 PERCENTAGE OF SSI RECIPIENT PATIENT DAYS TO MEDICARE 0.0381 4 PART A PATIENT DAYS 4.01 PERCENTAGE OF MEDICAID PATIENT DAYS TO TOTAL DAYS 0.3110 4.01 4.02 SUM OF 4 AND 4.01 0.3491 4.02 4.03 ALLOWABLE DISPROPORTIONATE SHARE PERCENTAGE 0.1802 4.03 4.04 DISPROPORTIONATE SHARE ADJUSTMENT 7162279 4.04 ADDITIONAL PAYMENT FOR HIGH PERCENTAGE OF ESRD BENEFICIARY DISCHARGES 5 TOTAL MEDICARE DISCHARGES ON WKST S-3, PART I EXCLUDING 5 DISCHARGES FOR DRGs 302, 316 AND 317 5.01 TOTAL ESRD MEDICARE DISCHARGES EXCLUDING DRGs 302, 5.01 316 AND 317 5.02 DIVIDE LINE 5.01 BY LINE 5 5.02 5.03 TOTAL MEDICARE ESRD INPATIENT DAYS EXCLUDING DRGs 5.03 302, 316 AND 317 5.04 RATIO OF AVERAGE LENGTH OF STAY TO ONE WEEK 5.04 5.05 AVERAGE WEEKLY COST FOR DIALYSIS TREATMENTS 5.05 5.06 TOTAL ADDITIONAL PAYMENT 5.06 6 SUBTOTAL 51065532 6 7 HOSPITAL SPECIFIC PAYMENTS 7 7.01 HOSPITAL SPECIFIC PAYMENTS (1996 HSR) 7.01 8 TOTAL PAYMENT FOR INPATIENT OPERATING COSTS 51065532 8 9 PAYMENT FOR INPATIENT PROGRAM CAPITAL 3797330 9 10 EXCEPTION PAYMENT FOR INPATIENT PROGRAM CAPITAL 10 11 DIRECT GRADUATE MEDICAL EDUCATION PAYMENT 11 11.01 NURSING AND ALLIED HEALTH MANAGED CARE 11.0111.02 ADD-ON PAYMENT FOR NEW TECHNOLOGIES 11.0212 NET ORGAN ACQUISITION COST 12 13 COST OF TEACHING PHYSICIANS 13 14 ROUTINE SERVICE OTHER PASS THROUGH COSTS 79475 14 15 ANCILLARY SERVICE OTHER PASS THROUGH COSTS 303224 15 16 TOTAL 55245561 16 17 PRIMARY PAYER PAYMENTS 67498 17 18 TOTAL AMOUNT PAYABLE FOR PROGRAM BENEFICIARIES 55178063 18 19 DEDUCTIBLES BILLED TO PROGRAM BENEFICIARIES 3472512 19 20 COINSURANCE BILLED TO PROGRAM BENEFICIARIES 191744 20 21 REIMBURSABLE BAD DEBTS 979896 21 21.01 REDUCED PROGRAM REIMBURSABLE BAD DEBTS 685927 21.0121.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE BENEFICIARIES 719081 21.0222 SUBTOTAL 52199734 22
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (05/2007) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART A PART A - INPATIENT HOSPITAL SERVICES UNDER PPS (CONT)
HOSPITAL SUB I SUB II SUB III SUB IV (14-0239)
23 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM PROVIDER 23 TERMINATION OR A DECREASE IN PROGRAM UTILIZATION 24 MEDI/MEDI BAD DEBT RETROACTIVE ADJ 24 25 AMOUNTS APPLICABLE TO PRIOR COST REPORTING PERIODS 25 RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS 26 AMOUNT DUE PROVIDER 52199734 26 27 SEQUESTRATION ADJUSTMENT 27 28 INTERIM PAYMENTS 51966059 28 28.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 28.0129 BALANCE DUE PROVIDER (PROGRAM) 233675 29 30 PROTESTED AMOUNTS (NONALLOWABLE COST REPORT ITEMS) 858518 30 IN ACCORDANCE WITH CMS PUB 15-II, SECTION 115.2
TO BE COMPLETED BY INTERMEDIARY50 OPERATING OUTLIER AMOUNT FROM WKST E, PART A, LINE 2.01 50 51 CAPITAL OUTLIER AMOUNT FROM WKST L, PART I, LINE 3.01 51 52 OPERATING OUTLIER RECONCILIATION AMOUNT (SEE INSTR.) 52 53 CAPITAL OUTLIER RECONILIATION AMOUNT (SEE INSTRUCTIONS) 53 54 THE RATE USED TO CALCULATE THE TIME VALUE OF MONEY 54 55 TIME VALUE OF MONEY (SEE INSTRUCTIONS) 55 56 CAPITAL TIME VALUE OF MONEY (SEE INSTRUCTIONS) 56
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART B
1 MEDICAL AND OTHER SERVICES 777 1 1.01 MEDICAL AND OTHER SERVICES RENDERED ON OR 16129745 1.01 AFTER AUGUST 1, 2000 1.02 PPS PAYMENTS RECEIVED INCLUDING OUTLIERS 14483228 1.02 1.03 1996 HOSPITAL SPECIFIC PAYMENT TO COST 0.864 1.03 RATIO 1.04 LINE 1.01 TIMES LINE 1.03 13936100 1.04 1.05 LINE 1.02 DIVIDED BY LINE 1.04 1.05 1.06 TRANSITIONAL CORRIDOR PAYMENT 1.06 1.07 AMOUNT FROM WORKSHEET D, PART IV, 182994 1.07 COLUMN 9, LINE 101 2 INTERNS AND RESIDENTS 2 3 ORGAN ACQUISITIONS 3 4 COST OF TEACHING PHYSICIANS 4 5 TOTAL COST 777 5
COMPUTATION OF LESSER OF COST OR CHARGES REASONABLE CHARGES 6 ANCILLARY SERVICE CHARGES 2377 6 7 INTERNS AND RESIDENTS SERVICE CHARGES 7 8 ORGAN ACQUISITION CHARGES 8 9 CHARGES OF PROFESSIONAL SERVICES OF 9 TEACHING PHYSICIANS 10 TOTAL REASONABLE CHARGES 2377 10
CUSTOMARY CHARGES11 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM 11 PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS 12 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM 12 PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 13 RATIO OF LINE 11 TO LINE 12 1314 TOTAL CUSTOMARY CHARGES 2377 1415 EXCESS OF CUSTOMARY CHGES OVER REASONABLE 1600 15 COST 16 EXCESS OF REASONABLE COST OVER CUSTOMARY 16 CHARGES 17 LESSER OF COST OR CHARGES 777 1717.01 TOTAL PPS PAYMENTS 14666222 17.01
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART B
COMPUTATION OF REIMBURSEMENT SETTLEMENT18 DEDUCTIBLES AND COINSURANCE 1818.01 DEDUCTIBLES AND COINSURANCE RELATING TO 3592916 18.01 LINE 17.01 19 SUBTOTAL 11074083 1920 SUM OF AMOUNTS FROM WKST E, PARTS C,D & E 2021 DIRECT GRADUATE MEDICAL EDUCATION PAYMENTS 2122 ESRD DIRECT MEDICAL EDUCATION COSTS 2223 SUBTOTAL 11074083 2324 PRIMARY PAYER PAYMENTS 12561 2425 SUBTOTAL 11061522 25 REIMBURSABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)26 COMPOSITE RATE ESRD 2627 BAD DEBTS 544743 2727.01 REDUCED REIMBURSABLE BAD DEBTS 381320 27.0127.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE 405898 27.02 BENEFICIARIES (SEE INSTRUCTIONS) 28 SUBTOTAL 11442842 2829 RECOVERY OF EXCESS DEPRECIATION RESULTING 29 FROM PROVIDER TERMINATION OR A DECREASE IN PROGRAM UTILIZATION 30 FORMULA DRIVEN OVERPAYMENT EST 3030.99 OTHER ADJUSTMENTS (MSP-LCC RECONCILIATION 30.99 AMOUNT) 31 AMOUNTS APPLICABLE TO PRIOR COST REPORTING 31 PERIODS RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS 32 SUBTOTAL 11442842 3233 SEQUESTRATION ADJUSTMENT 3334 INTERIM PAYMENTS 11580309 3434.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 34.0135 BALANCE DUE PROVIDER/PROGRAM -137467 3536 PROTESTED AMOUNTS (NONALLOWABLE COST 36 REPORT ITEMS) IN ACCORDANCE WITH CMS PUB 15-II, SECTION 115.2
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART B
PART B - MEDICAL AND OTHER HEALTH SERVICES
SUB I SUB I SUB I (14-S239) (14-S239) (14-S239) 1 1.01 1.02
1 MEDICAL AND OTHER SERVICES 1 1.01 MEDICAL AND OTHER SERVICES RENDERED ON OR 1.01 AFTER AUGUST 1, 2000 1.02 PPS PAYMENTS RECEIVED INCLUDING OUTLIERS 1.02 1.03 1996 HOSPITAL SPECIFIC PAYMENT TO COST 1.03 RATIO 1.04 LINE 1.01 TIMES LINE 1.03 1.04 1.05 LINE 1.02 DIVIDED BY LINE 1.04 1.05 1.06 TRANSITIONAL CORRIDOR PAYMENT 1.06 1.07 AMOUNT FROM WORKSHEET D, PART IV, 1.07 COLUMN 9, LINE 101 2 INTERNS AND RESIDENTS 2 3 ORGAN ACQUISITIONS 3 4 COST OF TEACHING PHYSICIANS 4 5 TOTAL COST 5
COMPUTATION OF LESSER OF COST OR CHARGES REASONABLE CHARGES 6 ANCILLARY SERVICE CHARGES 6 7 INTERNS AND RESIDENTS SERVICE CHARGES 7 8 ORGAN ACQUISITION CHARGES 8 9 CHARGES OF PROFESSIONAL SERVICES OF 9 TEACHING PHYSICIANS 10 TOTAL REASONABLE CHARGES 10
CUSTOMARY CHARGES11 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM 11 PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS 12 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM 12 PATIENTS LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 13 RATIO OF LINE 11 TO LINE 12 1314 TOTAL CUSTOMARY CHARGES 1415 EXCESS OF CUSTOMARY CHGES OVER REASONABLE 15 COST 16 EXCESS OF REASONABLE COST OVER CUSTOMARY 16 CHARGES 17 LESSER OF COST OR CHARGES 1717.01 TOTAL PPS PAYMENTS 17.01
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/2000) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART B
PART B - MEDICAL AND OTHER HEALTH SERVICES
SUB I SUB I SUB I (14-S239) (14-S239) (14-S239) 1 1.01 1.02
COMPUTATION OF REIMBURSEMENT SETTLEMENT18 DEDUCTIBLES AND COINSURANCE 1818.01 DEDUCTIBLES AND COINSURANCE RELATING TO 18.01 LINE 17.01 19 SUBTOTAL 1920 SUM OF AMOUNTS FROM WKST E, PARTS C,D & E 2021 DIRECT GRADUATE MEDICAL EDUCATION PAYMENTS 2122 ESRD DIRECT MEDICAL EDUCATION COSTS 2223 SUBTOTAL 2324 PRIMARY PAYER PAYMENTS 2425 SUBTOTAL 25 REIMBURSABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)26 COMPOSITE RATE ESRD 2627 BAD DEBTS 2727.01 REDUCED REIMBURSABLE BAD DEBTS 27.0127.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE 27.02 BENEFICIARIES (SEE INSTRUCTIONS) 28 SUBTOTAL 2829 RECOVERY OF EXCESS DEPRECIATION RESULTING 29 FROM PROVIDER TERMINATION OR A DECREASE IN PROGRAM UTILIZATION 30 FORMULA DRIVEN OVERPAYMENT EST 3030.99 OTHER ADJUSTMENTS (MSP-LCC RECONCILIATION 30.99 AMOUNT) 31 AMOUNTS APPLICABLE TO PRIOR COST REPORTING 31 PERIODS RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS 32 SUBTOTAL 3233 SEQUESTRATION ADJUSTMENT 3334 INTERIM PAYMENTS 3434.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 34.0135 BALANCE DUE PROVIDER/PROGRAM 3536 PROTESTED AMOUNTS (NONALLOWABLE COST 36 REPORT ITEMS) IN ACCORDANCE WITH CMS PUB 15-II, SECTION 115.2
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART C
PART C - OUTPATIENT AMBULATORY SURGICAL CENTER
[ ] TITLE V [XX] TITLE XVIII [ ] TITLE XIX
HOSPITAL (14-0239) OCTOBER 1, 1997 PRIOR TO ON OR AFTER 1 1.01
1 STANDARD OVERHEAD AMOUNTS (ASC FEES) 1 2 DEDUCTIBLES 2 3 SUBTOTAL 3 4 80 PERCENT OF LINE 3 4 5 ASC PORTION OF BLEND 5 6 OUTPATIENT ASC COST 6
COMPUTATION OF LESSER OF COST OR CHARGES 7 TOTAL CHARGES 7
CUSTOMARY CHARGES 8 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 8 ON A CHARGE BASIS 9 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 9 ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 10 RATIO OF LINE 8 TO LINE 9 1011 TOTAL CUSTOMARY CHARGES 1112 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 1213 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 1314 LESSER OF COST OR CHARGES 14
COMPUTATION OF REIMBURSEMENT SETTLEMENT15 DEDUCTIBLES AND COINSURANCE 1516 TOTAL 1617 HOSPITAL SPECIFIC PORTION OF BLEND 1718 ASC BLENDED AMOUNT 1819 LESSER OF LINES 16 OR 18 1920 PART B DEDUCTIBLES AND COINSURANCE 2021 ASC PAYMENT AMOUNT 21
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART D
PART D - OUTPATIENT RADIOLOGY SERVICES
[ ] TITLE V [XX] TITLE XVIII [ ] TITLE XIX
HOSPITAL (14-0239) OCTOBER 1, 1997 PRIOR TO ON OR AFTER 1 1.01
1 PREVAILING CHARGES 1 2 62 PERCENT OF LINE 1 2 3 DEDUCTIBLES 3 4 SUBTOTAL 4 5 BLENDED CHARGE PROPORTION 5 6 COST OF OUTPATIENT RADIOLOGY 6
COMPUTATION OF LESSER OF COST OR CHARGES 7 TOTAL CHARGES 7
CUSTOMARY CHARGES 8 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 8 ON A CHARGE BASIS 9 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICE 9 ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 10 RATIO OF LINE 8 TO LINE 9 1011 TOTAL CUSTOMARY CHARGES 1112 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 1213 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 1314 LESSER OF COST OR CHARGES 14
COMPUTATION OF REIMBURSEMENT SETTLEMENT15 DEDUCTIBLES AND COINSURANCE 1516 TOTAL 1617 COST PROPORTION 1718 OUTPATIENT RADIOLOGY BLENDED AMOUNT 1819 LESSER OF LINE 16 OR LINE 18 1920 PART B DEDUCTIBLES AND COINSURANCE 2021 RADIOLOGY PAYMENT AMOUNT 21
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E PART E
PART E - OTHER OUTPATIENT DIAGNOSTIC PROCEDURES
[ ] TITLE V [XX] TITLE XVIII [ ] TITLE XIX
HOSPITAL (14-0239) OCTOBER 1, 1997 PRIOR TO ON OR AFTER 1 1.01
1 PREVAILING CHARGES 1 2 42 PERCENT OF LINE 1 2 3 DEDUCTIBLES 3 4 SUBTOTAL 4 5 BLENDED CHARGE PROPORTION 5 6 COST OF OTHER OUTPATIENT DIAGNOSTIC PROCEDURES 6
COMPUTATION OF LESSER OF COST OR CHARGES 7 TOTAL CHARGES 7
CUSTOMARY CHARGES 8 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICES 8 ON A CHARGE BASIS 9 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE FOR PAYMENT FOR SERVICE 9 ON A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 10 RATIO OF LINE 8 TO LINE 9 1011 TOTAL CUSTOMARY CHARGES 1112 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 1213 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 1314 LESSER OF COST OR CHARGES 14
COMPUTATION OF REIMBURSEMENT SETTLEMENT15 DEDUCTIBLES AND COINSURANCE 1516 TOTAL 1617 COST PROPORTION 1718 OTHER OUTPATIENT DIAGNOSTIC BLENDED AMOUNT 1819 LESSER OF LINE 16 OR LINE 18 1920 PART B DEDUCTIBLES AND COINSURANCE 2021 DIAGNOSTIC PAYMENT AMOUNT 21
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED WORKSHEET E-1 HOSPITAL (14-0239) INPATIENT PART A PART B DESCRIPTION MM/DD/YYYY AMOUNT MM/DD/YYYY AMOUNT 1 2 3 4
1 TOTAL INTERIM PAYMENTS PAID TO PROVIDER 51882659 11580309 1 2 INTERIM PAYMENTS PAYABLE ON INDIVIDUAL BILLS EITHER NONE NONE 2 SUBMITTED OR TO BE SUBMITTED TO THE INTERMEDIARY FOR SERVICES RENDERED IN THE COST REPORTING PERIOD. IF NONE, WRITE 'NONE', OR ENTER A ZERO.3 LIST SEPARATELY EACH RETROACTIVE LUMP SUM .01 07/24/2008 83400 3.01 ADJUSTMENT AMOUNT BASED ON SUBSEQUENT PROGRAM .02 3.02 REVISION OF THE INTERIM RATE FOR THE COST TO .03 NONE 3.03 REPORTING PERIOD. ALSO SHOW DATE OF EACH PROVIDER .04 3.04 PAYMENT. IF NONE, WRITE 'NONE' OR ENTER A ZERO. .05 3.05 .50 3.50 PROVIDER .51 3.51 TO .52 NONE NONE 3.52 PROGRAM .53 3.53 .54 3.54
SUBTOTAL .99 83400 3.99
4 TOTAL INTERIM PAYMENTS 51966059 11580309 4
TO BE COMPLETED BY INTERMEDIARY
5 LIST SEPARATELY EACH TENTATIVE SETTLEMENT PAY- PROGRAM .01 5.01 MENT AFTER DESK REVIEW. ALSO SHOW DATE OF EACH TO .02 NONE NONE 5.02 PAYMENT. IF NONE, WRITE 'NONE' OR ENTER A ZERO. PROVIDER .03 5.03 PROVIDER .50 5.50 TO .51 NONE NONE 5.51 PROGRAM .52 5.52
SUBTOTAL .99 5.99 6 DETERMINED NET SETTLEMENT AMOUNT PROGRAM TO (BALANCE DUE) BASED ON THE COST PROVIDER .01 233675 6.01 REPORT. PROVIDER TO .02 -137467 6.02 PROGRAM7 TOTAL MEDICARE PROGRAM LIABILITY 52199734 11442842 7
NAME OF INTERMEDIARY: INTERMEDIARY NUMBER: _____________________________________________________ _____________SIGNATURE OF AUTHORIZED PERSON: DATE (MO/DAY/YR): ___________________________________________ ________________
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (11/98) 05/23/2009 10:27 ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED WORKSHEET E-1 SUBPROVIDER I (14-S239) INPATIENT PART A PART B DESCRIPTION MM/DD/YYYY AMOUNT MM/DD/YYYY AMOUNT 1 2 3 4
1 TOTAL INTERIM PAYMENTS PAID TO PROVIDER 416945 1 2 INTERIM PAYMENTS PAYABLE ON INDIVIDUAL BILLS EITHER NONE NONE 2 SUBMITTED OR TO BE SUBMITTED TO THE INTERMEDIARY FOR SERVICES RENDERED IN THE COST REPORTING PERIOD. IF NONE, WRITE 'NONE', OR ENTER A ZERO.3 LIST SEPARATELY EACH RETROACTIVE LUMP SUM .01 3.01 ADJUSTMENT AMOUNT BASED ON SUBSEQUENT PROGRAM .02 3.02 REVISION OF THE INTERIM RATE FOR THE COST TO .03 NONE NONE 3.03 REPORTING PERIOD. ALSO SHOW DATE OF EACH PROVIDER .04 3.04 PAYMENT. IF NONE, WRITE 'NONE' OR ENTER A ZERO. .05 3.05 .50 3.50 PROVIDER .51 3.51 TO .52 NONE NONE 3.52 PROGRAM .53 3.53 .54 3.54
SUBTOTAL .99 3.99
4 TOTAL INTERIM PAYMENTS 416945 4
TO BE COMPLETED BY INTERMEDIARY
5 LIST SEPARATELY EACH TENTATIVE SETTLEMENT PAY- PROGRAM .01 5.01 MENT AFTER DESK REVIEW. ALSO SHOW DATE OF EACH TO .02 NONE NONE 5.02 PAYMENT. IF NONE, WRITE 'NONE' OR ENTER A ZERO. PROVIDER .03 5.03 PROVIDER .50 5.50 TO .51 NONE NONE 5.51 PROGRAM .52 5.52
SUBTOTAL .99 5.99 6 DETERMINED NET SETTLEMENT AMOUNT PROGRAM TO (BALANCE DUE) BASED ON THE COST PROVIDER .01 2366 6.01 REPORT. PROVIDER TO .02 6.02 PROGRAM7 TOTAL MEDICARE PROGRAM LIABILITY 419311 7
NAME OF INTERMEDIARY: INTERMEDIARY NUMBER: _____________________________________________________ _____________SIGNATURE OF AUTHORIZED PERSON: DATE (MO/DAY/YR): ___________________________________________ ________________
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (5/2007) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E-3 PART I MEDICARE PART A SERVICES - TEFRA HOSPITAL SUB I SUB II SUB III SUB IV (14-S239) 1 INPATIENT HOSPITAL SERVICES 1 1.01 HOSPITAL SPECIFIC AMOUNT (SEE INSTRUCTIONS) 1.01 1.02 NET FEDERAL PPS PAYMENTS (SEE INSTRUCTIONS) 1.02 1.03 MEDICARE SSI RATIO (IRF PPS ONLY) (SEE INSTR.) 1.03 1.04 INPATIENT REHAB LIP PAYMENTS (SEE INSTRUCTIONS) 1.04 1.05 OUTLIER PAYMENTS 1.05 1.06 TOTAL PPS PAYMENTS 1.06 1.07 NURSING AND ALLIED HEALTH MANAGED CARE PAYMENT 1.07
INPATIENT PSYCHIATRIC FACILITY (IPF) 1.08 NET FEDERAL IPF PPS PAYMENTS (EXCLUDING OUTLIER, 504057 1.08 STOP-LOSS, ECT, AND TEACHING ADJUSTMENT) 1.09 NET IPF PPS OUTLIER PAYMENTS 6488 1.09 1.10 NET IPF PPS ECT PAYMENTS 1.10 1.11 UNWEIGHTED INTERN AND RESIDENT FTE COUNT FOR 1.11 LATEST COST REPORT FILED PRIOR TO NOVEMBER 15, 2004. (SEE INSTRUCTIONS) 1.12 NEW TEACHING PROGRAM ADJUSTMENT (SEE INSTR.) 1.12 1.13 CURRENT YEAR'S UNWEIGHTED FTE COUNT OF I&R 1.13 OTHER THAN FTES IN THE FIRST 3 YEARS OF A 'NEW TEACHING PROGRAM'. (SEE INSTR.) 1.14 CURRENT YEAR'S UNWEIGHTED I&R FTE COUNT FOR 1.14 RESIDENTS WITHIN THE FIRST 3 YEARS OF A 'NEW TEACHING PROGRAM'. (SEE INSTR.) 1.15 INTERN AND RESIDENT COUNT FOR IPF PPS MEDICAL 1.15 EDUCATION ADJUSTMENT (SEE INSTRUCTIONS) 1.16 AVERAGE DAILY CENSUS (SEE INSTRUCTIONS) 8.081967 1.16 1.17 MEDICAL EDUCATION ADJUSTMENT FACTOR 1.17 1.18 MEDICAL EDUCATION ADJUSTMENT 1.18 1.19 ADJUSTED NET IPF PPS PAYMENTS 510545 1.19 1.20 STOP LESS PAYMENT FLOOR 1.20 1.21 ADJUSTED NET PAYMENT FLOOR 1.21 1.22 STOP LOSS ADJUSTMENT 1.22 1.23 TOTAL IPF PPS PAYMENTS 510545 1.23
INPATIENT REHABILITATION FACILITY (IRF) 1.35 UNWEIGHTED INTERN AND RESIDENT FTE COUNT FOR 1.35 COST REPORT PERIODS ENDING ON/OR PRIOR TO NOVEMBER 15, 2004. (SEE INSTRUCTIONS) 1.36 NEW TEACHING PROGRAM ADJUSTMENT. (SEE INSTR.) 1.36 1.37 CURRENT YEAR'S UNWEIGHTED FTE COUNT OF I&R OTHER 1.37 THAN FTEs IN THE FIRST 3 YEARS OF A "NEW TEACHING PROGRAM". (SEE INSTRUCTIONS) 1.38 CURRENT YEAR'S UNWEIGHTED I&R FTE COUNT FOR 1.38 RESIDENTS WITHIN THE FIRST 3 YEARS OF A "NEW TEACHING PROGRAM". (SEE INSTRUCTIONS) 1.39 INTERN AND RESIDENT COUNT FOR IRF PPS MEDICAL 1.39 EDUCATION ADJUSTMENT. (SEE INSTRUCTIONS) 1.40 AVERAGE DAILY CENSUS. (SEE INSTRUCTIONS) 1.40 1.41 MEDICAL EDUCATION ADJUSTMENT FACTOR 1.41 1.42 MEDICAL EDUCATION ADJUSTMENT 1.42
2 ORGAN ACQUISITION 2 3 COST OF TEACHING PHYSICIANS 3 4 SUBTOTAL 510545 4 5 PRIMARY PAYER PAYMENTS 5 6 SUBTOTAL 510545 6 7 DEDUCTIBLES 85984 7 8 SUBTOTAL 424561 8 9 COINSURANCE 7616 910 SUBTOTAL 416945 1011 REIMBURSABLE BAD DEBTS (EXCLUDE BAD DEBTS 11 FOR PROFESSIONAL SERVICES) 11.01 REDUCED REIMBURSABLE BAD DEBTS 11.0111.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE 11.02 BENEFICIARIES (SEE INSTRUCTIONS) 12 SUBTOTAL 416945 1213 DIRECT GRADUATE MEDICAL EDUCATION PAYMENTS 13
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (5/2007) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E-3 PART I MEDICARE PART A SERVICES - TEFRA HOSPITAL SUB I SUB II SUB III SUB IV (14-S239) 13.01 OTHER PASS THROUGH COSTS (SEE INSTRUCTIONS) 2366 13.0114 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM 14 PROVIDER TERMINATION OR A DECREASE IN PROGRAM UTILIZATION 15 OTHER ADJUSTMENTS 1516 AMOUNTS APPLICABLE TO PRIOR COST REPORTING 16 PERIODS RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS 17 TOTAL AMOUNT PAYABLE TO THE PROVIDER 419311 1718 SEQUESTRATION ADJUSTMENT 1819 INTERIM PAYMENTS 416945 1919.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 19.0120 BALANCE DUE PROVIDER/PROGRAM 2366 2021 PROTESTED AMOUNTS (NONALLOWABLE COST REPORT 21 ITEMS) IN ACCORDANCE WITH CMS PUB 15-II, SECTION 115.2
TO BE COMPLETED BY INTERMEDIARY50 ORIGINAL OUTLIER AMOUNT 5051 OUTLIER RECONCILIATION AMOUNT (SEE INSTRUCTIONS) 5152 THE RATE USED TO CALCULATE THE TIME VALUE OF 52 MONEY 53 OPERATING TIME VALUE OF MONEY (SEE INSTRUCTIONS) 53
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/1999) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E-3 PART III - TITLE V OR TITLE XIX SERVICES OR TITLE XVIII SNF PPS ONLY PART III
[ ] TITLE V [ ] TITLE XVIII [XX] TITLE XIX
HOSPITAL SUB I SUB II SUB III SUB IV NF I (14-0239) (14-S239) (OTHER) (OTHER) COMPUTATION OF NET COST OF COVERED SERVICES 1 1 1 1 1 1 1 INPATIENT HOSPITAL/SNF/NF SERVICES 20950357 777528 1 2 MEDICAL AND OTHER SERVICES 2 3 INTERNS AND RESIDENTS 3 4 ORGAN ACQUISITION CERTIFIED TRANSPLANT CENTERS O 4 5 COST OF TEACHING PHYSICIANS 5 6 SUBTOTAL 20950357 777528 6 7 INPATIENT PRIMARY PAYER PAYMENTS 7 8 OUTPATIENT PRIMARY PAYER PAYMENTS 8 9 SUBTOTAL 20950357 777528 9
COMPUTATION OF LESSER OF COST OR CHARGES10 ROUTINE SERVICE CHARGES 1011 ANCILLARY SERVICE CHARGES 1112 INTERNS AND RESIDENTS SERVICE CHARGES 1213 ORGAN ACQUISITION CHARGES, NET OF REVENUE 1314 TEACHING PHYSICIANS 1415 INCENTIVE FROM TARGET AMOUNT COMPUTATION 1516 TOTAL REASONABLE CHARGES 16
CUSTOMARY CHARGES17 AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE 1718 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM 18 A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 19 RATIO OF LINE 17 TO LINE 18 1920 TOTAL CUSTOMARY CHARGES 2021 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 2122 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 20950357 777528 2223 COST OF COVERED SERVICES 20950357 777528 23
PROSPECTIVE PAYMENT AMOUNT24 OTHER THAN OUTLIER PAYMENTS 2425 OUTLIER PAYMENTS 2526 PROGRAM CAPITAL PAYMENTS 2627 CAPITAL EXCEPTION PAYMENTS 2728 ROUTINE SERVICE OTHER PASS THROUGH COSTS 2829 ANCILLARY SERVICE OTHER PASS THROUGH COSTS 2930 SUBTOTAL 20950357 777528 3031 CUSTOMARY CHARGES (TITLE XIX PPS COVERED 3132 LESSER OF LINES 30 OR 31 20950357 777528 3233 DEDUCTIBLES (EXCLUDE PROFESSIONAL COMPONENT) 33
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/1999) 05/23/2009 10:27 CALCULATION OF REIMBURSEMENT SETTLEMENT WORKSHEET E-3 PART III - TITLE V OR TITLE XIX SERVICES OR TITLE XVIII SNF PPS ONLY PART III
[ ] TITLE V [ ] TITLE XVIII [XX] TITLE XIX
HOSPITAL SUB I SUB II SUB III SUB IV NF I (14-0239) (14-S239) (OTHER) (OTHER) 1 1 1 1 1 1
COMPUTATION OF REIMBURSEMENT SETTLEMENT34 EXCESS OF REASONABLE COST 20950357 777528 3435 SUBTOTAL 3536 COINSURANCE 3637 SUM OF AMOUNTS FROM WKST E, PARTS C,D AND E, 3738 REIMBURSABLE BAD DEBTS 3838.01 REDUCED REIMBURSABLE BAD DEBTS 38.0138.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE 38.02 BENEFICIARIES (SEE INSTRUCTIONS) 39 UTILIZATION REVIEW 3940 SUBTOTAL 4041 INPATIENT ROUTINE SERVICE COST 4142 MEDICARE INPATIENT ROUTINE CHARGES 4243 AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE 4344 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM 44 A CHARGE BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(E) 45 RATIO OF LINE 43 TO LINE 44 4546 TOTAL CUSTOMARY CHARGES 4647 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 4748 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES 4849 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM 49 UTILIZATION 50 OTHER ADJUSTMENTS 5051 AMOUNTS APPLICABLE TO PRIOR COST REPORTING 51 DEPRECIABLE ASSETS 52 SUBTOTAL 5253 INDIRECT MEDICAL EDUCATION ADJUSTMENT 5354 DIRECT GRADUATE MEDICAL EDUCATION PAYMENTS 5455 TOTAL AMOUNT PAYABLE TO THE PROVIDER 5556 SEQUESTRATION ADJUSTMENT 5657 INTERIM PAYMENTS 5757.01 TENTATIVE SETTLEMENT (FOR FI USE ONLY) 57.0158 BALANCE DUE PROVIDER/PROGRAM 5859 PROTESTED AMOUNTS (NONALLOWABLE COST REPORT 59 SECTION 115.2
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 BALANCE SHEET WORKSHEET G
ASSETS GENERAL SPECIFIC ENDOWMENT PLANT FUND PURPOSE FUND FUND FUND 1 2 3 4 CURRENT ASSETS 1 CASH ON HAND AND IN BANKS 16695084 1 2 TEMPORARY INVESTMENTS 2 3 NOTES RECEIVABLE 3 4 ACCOUNTS RECEIVABLE 107367086 4 5 OTHER RECEIVABLES 10503711 5 6 ALLOWANCE FOR UNCOLLECTIBLE NOTES & ACCOUNTS RECEIVABLE -68157877 6 7 INVENTORY 5164115 7 8 PREPAID EXPENSES 3507993 8 9 OTHER CURRENT ASSETS 11678228 9 10 DUE FROM OTHER FUNDS 10 11 TOTAL CURRENT ASSETS 86758340 11
OTHER ASSETS22 INVESTMENTS 119560701 22 23 DEPOSITS ON LEASES 23 24 DUE FROM OWNERS/OFFICERS 24 25 OTHER ASSETS 19527006 25 26 TOTAL OTHER ASSETS 139087707 26
27 TOTAL ASSETS 317702207 27
LIABILITIES AND FUND BALANCES GENERAL SPECIFIC ENDOWMENT PLANT FUND PURPOSE FUND FUND FUND 1 2 3 4 CURRENT LIABILITIES28 ACCOUNTS PAYABLE 8452958 28 29 SALARIES, WAGES & FEES PAYABLE 35669787 29 30 PAYROLL TAXES PAYABLE 30 31 NOTES & LOANS PAYABLE (SHORT TERM) 2899648 31 32 DEFERRED INCOME 32 33 ACCELERATED PAYMENTS 33 34 DUE TO OTHER FUNDS 34 35 OTHER CURRENT LIABILITIES 10835944 35 36 TOTAL CURRENT LIABILITIES 57858337 36
LONG-TERM LIABILITIES37 MORTGAGE PAYABLE 37 38 NOTES PAYABLE 74108920 38 39 UNSECURED LOANS 39 40 LOANS FROM OWNERS .01 PRIOR TO 7/1/66 40 .02 ON OR AFTER 7/1/66 41 OTHER LONG TERM LIABILITIES 74927914 41 42 TOTAL LONG TERM LIABILITIES 149036834 42 43 TOTAL LIABILITIES 206895171 43
CAPITAL ACCOUNTS44 GENERAL FUND BALANCE 110807036 44 45 SPECIFIC PURPOSE FUND BALANCE 45 46 DONOR CREATED-ENDOWMENT FUND BAL-RESTRICTED 46 47 DONOR CREATED-ENDOWMENT FUND BAL-UNRESTRICTED 47 48 GOVERNING BODY CREATED - ENDOWMENT FUND BAL 48 49 PLANT FUND BALANCE - INVESTED IN PLANT 49 50 PLANT FUND BALANCE - RESERVE FOR PLANT 50 IMPROVEMENT, REPLACEMENT AND EXPANSION51 TOTAL FUND BALANCES 110807036 51
52 TOTAL LIABILITIES AND FUND BALANCES 317702207 52
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 STATEMENT OF CHANGES IN FUND BALANCES WORKSHEET G-1
GENERAL FUND SPECIFIC PURPOSE FUND ENDOWMENT FUND PLANT FUND 1 2 3 4
1 FUND BALANCES AT BEGINNING OF PERIOD 172786873 1
2 NET INCOME (LOSS) 4555039 2
3 TOTAL 177341912 3
4 ADDITIONS (CREDIT ADJUSTMENTS) 4
5 FAS 124 FAS 115 5
6 FAS 133 6
7 INCREASE IN TEMP REST ASSETS 7
8 OTHER 8
9 OTHER 9
10 TOTAL ADDITIONS 10
11 SUBTOTAL 177341912 11
12 DEDUCTIONS (DEBIT ADJUSTMENTS) 12
13 OTHER 66534876 13
14 TRANSFER TO AFFILIATES 14
15 OTHER 15
16 OTHER 16
17 17
18 TOTAL DEDUCTIONS 66534876 18
19 FUND BALANCE AT END OF PERIOD 110807036 19 PER BALANCE SHEET
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES WORKSHEET G-2 PARTS I & II PART I - PATIENT REVENUES
REVENUE CENTER INPATIENT OUTPATIENT TOTAL 1 2 3 GENERAL INPATIENT ROUTINE CARE SERVICES 1 HOSPITAL 55676659 55676659 1 2 SUBPROVIDER I 3490586 3490586 2 4 SWING BED - SNF 4 5 SWING BED - NF 5 6 SKILLED NURSING FACILITY 6 7 NURSING FACILITY 7 8 OTHER LONG TERM CARE 8 9 TOTAL GENERAL INPATIENT CARE SERVICES 59167245 59167245 9 INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICES 10 INTENSIVE CARE UNIT 16746075 16746075 10 11 CORONARY CARE UNIT 11 12 BURN INTENSIVE CARE UNIT 12 13 SURGICAL INTENSIVE CARE UNIT 13 13.01 NEONATAL INTENSIVE CARE 40396834 40396834 13.01 13.02 PEDIATRIC INTENSIVE CARE 2892106 2892106 13.02 14 OTHER SPECIAL CARE (SPECIFY) 14 15 TOTAL INTENSIVE CARE TYPE INPATIENT HOSPITAL SERVICE 60035015 60035015 15 16 TOTAL INPATIENT ROUTINE CARE SERVICES 119202260 119202260 16 17 ANCILLARY SERVICES 339706817 226660046 566366863 17 18 OUTPATIENT SERVICES 18 18.50 RHC 18.50 18.60 FQHC 18.60 19 HOME HEALTH AGENCY 19 20 AMBULANCE 5960449 5960449 20 21 CORF 21 22 ASC 22 23 HOSPICE 23 24 24 25 TOTAL PATIENT REVENUES 458909077 232620495 691529572 25
PART II - OPERATING EXPENSES 1 2 26 OPERATING EXPENSES 270387485 26 27 ADD (SPECIFY) 27 28 BAD DEBTS 19378710 28 29 29 30 30 31 31 32 32 33 TOTAL ADDITIONS 19378710 33 34 DEDUCT (SPECIFY) 34 35 PHYSICIAN PRACTICE REVENUE -621124 35 36 36 37 37 38 38 39 TOTAL DEDUCTIONS -621124 39 40 TOTAL OPERATING EXPENSES 289145071 40
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 STATEMENT OF REVENUES AND EXPENSES WORKSHEET G-3
DESCRIPTION
1 TOTAL PATIENT REVENUES 691529572 1 2 LESS - CONTRACTUAL ALLOWANCES AND DISCOUNTS ON PATIENTS' ACCOUNTS 381740245 2 3 NET PATIENT REVENUES 309789327 3 4 LESS - TOTAL OPERATING EXPENSES 289145071 4 5 NET INCOME FROM SERVICE TO PATIENTS 20644256 5
6 CONTRIBUTIONS, DONATIONS, BEQUESTS, ETC. 6 7 INCOME FROM INVESTMENTS 7 8 REVENUE FROM TELEPHONE AND TELEGRAPH SERVICE 8 9 REVENUE FROM TELEVISION AND RADIO SERVICE 910 PURCHASE DISCOUNTS 1011 REBATES AND REFUNDS OF EXPENSES 1112 PARKING LOT RECEIPTS 1213 REVENUE FROM LAUNDRY AND LINEN SERVICE 1314 REVENUE FROM MEALS SOLD TO EMPLOYEES AND GUESTS 1415 REVENUE FROM RENTAL OF LIVING QUARTERS 1516 REV FROM SALE OF MED & SURG SUPP TO OTHER THAN PATIENTS 1617 REVENUE FROM SALE OF DRUGS TO OTHER THAN PATIENTS 1718 REVENUE FROM SALE OF MEDICAL RECORDS AND ABSTRACTS 1819 TUITION (FEES, SALE OF TEXTBOOKS, UNIFORMS, ETC.) 1920 REVENUE FROM GIFTS, FLOWER, COFFEE SHOPS, CANTEEN 2021 RENTAL OF VENDING MACHINES 2122 RENTAL OF HOSPITAL SPACE 2223 GOVERNMENTAL APPROPRIATIONS 2324 OTHER OPERATING INCOME 20819189 2425 TOTAL OTHER INCOME 20819189 2526 TOTAL 41463445 2627 NON OPERATING LOSS 36908406 2728 2829 2930 TOTAL OTHER EXPENSES 36908406 3031 NET INCOME (OR LOSS) FOR THE PERIOD 4555039 31
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/97) 05/23/2009 10:27 CALCULATION OF CAPITAL PAYMENT - TITLE XVIII - FULLY PROSPECTIVE METHOD WORKSHEET L
HOSPITAL SUB I SUB II SUB III SUB IV (14-0239) (14-S239) PART I - FULLY PROSPECTIVE METHOD
1 CAPITAL HOSPITAL SPECIFIC RATE PAYMENTS 1 CAPITAL FEDERAL AMOUNT 2 CAPITAL DRG OTHER THAN OUTLIER 3363659 2 3 CAPITAL DRG OUTLIER PAYMENTS FOR SERVICES RENDERED 3 PRIOR TO OCTOBER 1, 1997 3.01 CAPITAL DRG OUTLIER PAYMENTS FOR SERVICES RENDERED 187115 3.01 ON OR AFTER OCTOBER 1, 1997 INDIRECT MEDICAL EDUCATION ADJUSTMENT 4 TOTAL INPAT DAYS DIVIDED BY NO OF DAYS IN CR PERIOD 4 [ E-3,PT VI,LN.18] [E,PT A,LN.3.17][x E-3,PT VI,LN.1] 4.01 NO. OF INTERNS & RESIDENTS 0.00 0.00 4.01 4.02 INDIRECT MEDICAL EDUCATION PERCENTAGE 4.02 4.03 INDIRECT MEDICAL EDUCATON ADJUSTMENT 4.03 DISPROPORTIONATE SHARE ADJUSTMENT 5 % OF SSI RECIPIENT PAT DAYS TO MEDICARE PART A PAT DAYS 0.0381 5 5.01 % OF MEDICAID PAT DAYS TO TOTAL DAYS ON WKST S-3, PART I 0.3110 5.01 5.02 SUM OF LINES 5 AND 5.01 0.3491 5.02 5.03 ALLOWABLE DISPROPORTIONATE SHARE PERCENTAGE 0.0733 5.03 5.04 DISPROPORTIONATE SHARE ADJUSTMENT 246556 5.04 6 TOTAL PROSPECTIVE CAPITAL PAYMENTS 3797330 6
PART II - HOLD HARMLESS METHOD
1 NEW CAPITAL 1 2 OLD CAPITAL 2 3 TOTAL CAPITAL 3 4 RATIO OF NEW CAPITAL TO TOTAL CAPITAL 4 5 TOTAL CAPITAL PAYMENTS UNDER 100% FEDERAL RATE 5 6 REDUCTION FACTOR FOR HOLD HARMLESS PAYMENT 6 7 REDUCED OLD CAPITAL AMOUNT 7 8 HOLD HARMLESS PAYMENT FOR NEW CAPITAL 8 9 SUBTOTAL 9 10 PAYMENT UNDER HOLD HARMLESS (GREATER OF LINE 5 OR LINE 9) 10
PART III - PAYMENT UNDER REASONABLE COST
1 PROGRAM INPATIENT ROUTINE CAPITAL COST 1 2 PROGRAM INPATIENT ANCILLARY CAPITAL COST 2 3 TOTAL INPATIENT PROGRAM CAPITAL 3 4 CAPITAL COST PAYMENT FACTOR 4 5 TOTAL INPATIENT PROGRAM CAPITAL COST 5
PART IV - COMPUTATION OF EXCEPTION PAYMENTS
1 PROGRAM INPATIENT CAPITAL COSTS 1 2 PROGRAM INPATIENT CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES 2 3 NET PROGRAM INPATIENT CAPITAL COSTS 3 4 APPLICABLE EXCEPTION PERCENTAGE 4 5 CAPITAL COST FOR COMPARISON TO PAYMENTS 5 6 PERCENTAGE ADJUSTMENT FOR EXTRAORDINARY CIRCUMSTANCES 6 7 ADJUSTMENT TO CAPITAL MINIMUM PAYMENT LEVEL FOR 7 EXTRAORDINARY CIRCUMSTANCES 8 CAPITAL MINIMUM PAYMENT LEVEL 8 9 CURRENT YEAR CAPITAL PAYMENTS 9 10 CURRENT YEAR COMPARISON OF CAPITAL MINIMUM PAYMENT LEVEL 10 TO CAPITAL PAYMENTS11 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL 11 OVER CAPITAL PAYMENT12 NET COMPARISON OF CAPITAL MINIMUM PYMNT LEVEL TO CAPITAL PYMNTS 12 13 CURRENT YEAR EXCEPTION PAYMENT 13 14 CARRYOVER OF ACCUMULATED CAPITAL MINIMUM PAYMENT LEVEL 14 OVER CAPITAL PAYMENT FOR FOLLOWING PERIOD15 CURRENT YEAR ALLOWABLE OPERATING AND CAPITAL PAYMENT 15 (SEE INSTRUCTIONS)16 CURRENT YEAR OPERATING AND CAPITAL COSTS (SEE INSTRUCTIONS) 16 17 CURRENT YEAR EXCEPTION OFFSET AMOUNT 17
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 ALLOCATION OF ALLOWABLE CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES WORKSHEET L-1 PART I
EXTRAORDI- I&R COST & COST CENTER DESCRIPTION NARY CAP- SUBTOTAL SUBTOTAL POST STEP- TOTAL REL COSTS DOWN ADJS 0 4A 25 26 27
GENERAL SERVICE COST CENTERS 1 OLD CAP REL COSTS-BLDG & FIXT 1 2 OLD CAP REL COSTS-MVBLE EQUIP 2 3 NEW CAP REL COSTS-BLDG & FIXT 3 4 NEW CAP REL COSTS-MVBLE EQUIP 4 5 EMPLOYEE BENEFITS 5 6 ADMINISTRATIVE & GENERAL 6 7 MAINTENANCE & REPAIRS 7 8 OPERATION OF PLANT 8 9 LAUNDRY & LINEN SERVICE 9 10 HOUSEKEEPING 10 11 DIETARY 11 12 CAFETERIA 12 13 MAINTENANCE OF PERSONNEL 13 14 NURSING ADMINISTRATION 14 15 CENTRAL SERVICES & SUPPLY 15 16 PHARMACY 16 17 MEDICAL RECORDS & LIBRARY 17 18 SOCIAL SERVICE 18 20 NONPHYSICIAN ANESTHETISTS 20 21 NURSING SCHOOL 21 22 I&R SERVICES-SALARY & FRINGES A 22 23 I&R SERVICES-OTHER PRGM COSTS A 23 24 PARAMDICAL ED PROGRAM XRAY 24 24.01 PASTORAL EDUCATION PROGRAM 24.0124.02 PARAMED EDUC EMT PROGRAM 24.02 INPATIENT ROUTINE SERV COST CENTERS25 ADULTS & PEDIATRICS 25 26 INTENSIVE CARE UNIT 26 29.01 NEONATAL INTENSIVE CARE 29.0129.02 PEDIATRIC INTENSIVE CARE 29.0231 SUBPROVIDER I 31 33 NURSERY 33 ANCILLARY SERVICE COST CENTERS37 OPERATING ROOM 37 38 RECOVERY ROOM 38 39 DELIVERY ROOM & LABOR ROOM 39 40 ANESTHESIOLOGY 40 41 RADIOLOGY-DIAGNOSTIC 41 42 RADIOLOGY-THERAPEUTIC 42 43 RADIOISOTOPE 43 44 LABORATORY 44 46.30 BLOOD CLOTTING FACTORS ADMIN CO 46.3047 BLOOD STORING, PROCESSING & TRA 47 49 RESPIRATORY THERAPY 49 50 PHYSICAL THERAPY 50 53 ELECTROCARDIOLOGY 53 54 ELECTROENCEPHALOGRAPHY 54 55 MEDICAL SUPPLIES CHARGED TO PAT 55 56 DRUGS CHARGED TO PATIENTS 56 57 RENAL DIALYSIS 57 59 GI LAB 59 59.01 MRI 59.0159.02 CT SCAN 59.0259.03 CARDIAC CATHETERIZATION 59.0359.04 PRIMARY PREVENTION PROGRAM 59.0459.05 WOMEN'S HEALTH ADVANTAGE 59.0559.07 OUTPATIENT DETOX 59.0759.08 SPECIAL SURGICAL SERVICES 59.0859.10 GENETIC SERVICES 59.1059.11 CARDIOLOGY 59.1159.12 OUTPATIENT PSYCH SERVICES 59.12 OUTPATIENT SERVICE COST CENTERS60.01 PAIN CENTER 60.0160.02 ANTENATAL TEST CENTER 60.0260.03 CHILD PSYCHIATRIC CLINIC 60.0361 EMERGENCY 61 62 OBSERVATION BEDS (NON-DISTINCT 62 63.50 RHC 63.5063.60 FQHC 63.60 OTHER REIMBURSABLE COST CENTERS65 AMBULANCE SERVICES 65 68 AIR AMBULANCE 68 69.10 CMHC 69.1069.20 OUTPATIENT PHYSICAL THERAPY 69.20
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 IN LIEU OF FORM CMS-2552-96 (9/96) 05/23/2009 10:27 ALLOCATION OF ALLOWABLE CAPITAL COSTS FOR EXTRAORDINARY CIRCUMSTANCES WORKSHEET L-1 PART I
EXTRAORDI- I&R COST & COST CENTER DESCRIPTION NARY CAP- SUBTOTAL SUBTOTAL POST STEP- TOTAL REL COSTS DOWN ADJS 0 4A 25 26 27
69.30 OUTPATIENT OCCUPATIONAL THERAPY 69.3069.40 OUTPATIENT SPEECH PATHOLOGY 69.4071 HOME HEALTH AGENCY 71 SPECIAL PURPOSE COST CENTERS85.01 PANCREAS ACQUISITION 85.0185.02 INTESTINAL ACQUISITION 85.0285.03 ISLET CELL ACQUISITION 85.0395 SUBTOTALS 95 NONREIMBURSABLE COST CENTERS98 PHYSICIANS' PRIVATE OFFICES 98 00 GUEST CENTER 00 00.01 OTHER NONREIMBURSEABLE COST CEN 00.0100.02 COMMUNITY SERVICES 00.0200.04 AUXILIARY 00.0400.07 ROCKFORD HEALTH SYSTEM 00.0700.08 DIALYSIS RENTED SPACE 00.08101 CROSS FOOT ADJUSTMENTS 101102 NEGATIVE COST CENTER 102103 TOTAL 103104 TOTAL STATISTICAL BASIS 104105 UNIT COST MULTIPLIER 105105 UNIT COST MULTIPLIER 105
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 CMS-2552-96 - SUMMARY REPORT 97 05/23/2009 10:27
---- TITLE XVIII ---- ----- TITLE XIX ----- ------ TITLE V ------ TOTAL THIRD COST CENTERS PART A PART B INPATIENT OUTPATIENT INPATIENT OUTPATIENT PARTY UTIL 1 2 3 4 5 6 7
UTILIZATION PERCENTAGES BASED ON DAYS 25 ADULTS & PEDIATRICS 43.32 20.02 63.34 25 26 INTENSIVE CARE UNIT 56.01 6.63 62.64 26 29.01 NEONATAL INTENSIVE CARE 48.46 48.46 29.01 29.02 PEDIATRIC INTENSIVE CARE 51.10 51.10 29.02 33 NURSERY 97.75 97.75 33
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 CMS-2552-96 - SUMMARY REPORT 97 05/23/2009 10:27
***** REPORT 97 ***** UTILIZATION STATISTICS ***** SUBPROVIDER I
---- TITLE XVIII ---- ----- TITLE XIX ----- ------ TITLE V ------ TOTAL THIRD COST CENTERS PART A PART B INPATIENT OUTPATIENT INPATIENT OUTPATIENT PARTY UTIL 1 2 3 4 5 6 7
UTILIZATION PERCENTAGES BASED ON DAYS 31 SUBPROVIDER I 24.04 28.47 52.51 31
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 05/23/2009
APPORTIONMENT OF INPATIENT MEDICARE ANCILLARY SERVICE PPS CAPITAL COSTS
RATIO MEDICARE CAPITAL CAPITAL INPATIENT INPATIENT COST CENTER DESCRIPTION RELATED TOTAL COST TO PROGRAM PPS CAPITAL COSTS CHARGES CHARGES CHARGES COSTS 1 2 3 4 5
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 05/23/2009
APPORTIONMENT OF INPATIENT MEDICARE ROUTINE SERVICE PPS CAPITAL COSTS
MEDICARE CAPITAL SWING-BED TOTAL INPATIENT INPATIENT COST CENTER DESCRIPTION RELATED ADJUSTMENT TOTAL PATIENT PER PROGRAM PPS CAPITAL COSTS AMOUNT COST DAYS DIEM DAYS COSTS 1 2 3 4 5 6 7
INPATIENT ROUTINE SERVICE COST CENTERS 25 ADULTS & PEDIATRICS 2890303 2890303 55150 52.41 23893 1252232 25 26 INTENSIVE CARE UNIT 458172 458172 5794 79.08 3245 256615 26 29.01 NEONATAL INTENSIVE CARE 554024 554024 12208 45.38 29.01 29.02 PEDIATRIC INTENSIVE CARE 117484 117484 908 129.39 29.02101 TOTAL 4019983 4019983 27138 1508847 101
MEDICARE INPATIENT ROUTINE SERVICE PPS CAPITAL COSTS 1508847
MEDICARE INPATIENT ANCILLARY SERVICE PPS CAPITAL COSTS 2880375
TOTAL MEDICARE INPATIENT PPS CAPITAL COSTS 4389222
MEDICARE DISCHARGES (WORKSHEET S-3, LINE 8, COLUMN 13)
MEDICARE PATIENT DAYS (WORKSHEET S-3, LINE 8, COLUMN 4)
PER DISCHARGE CAPITAL COSTS
PER DIEM CAPITAL COSTS
PROVIDER NO. 14-0239 ROCKFORD MEMORIAL HOSPITAL KPMG LLP COMPU-MAX MICRO SYSTEM VERSION: 2008.05PERIOD FROM 01/01/2008 TO 12/31/2008 05/23/2009
I. COST TO CHARGE RATIO FOR PPS HOSPITALS
1. TOTAL PROGRAM (TITLE XVIII) INPATIENT OPERATING COST EXCLUDING CAPITAL RELATED, NONPHYSICIAN ANESTHETIST AND MEDICAL EDUCATION COST. 64855611 (WORKSHEET D-1 PART II LINE 53)
2. HOSPITAL PART A TITLE XVIII CHARGES 173243220 (SUM OF INPATIENT CHARGES AND ANCILLARY CHARGES ON WKST D-4 FOR HOSPITAL TITLE XVIII COMPONENT)
3. RATIO OF COST TO CHARGES (LINE 1 / LINE 2) .374
COST TO CHARGE RATIO FOR PSYCH SUBPROVIDER
1. TOTAL MEDICARE COSTS 771376 (WKST D-1 PART II LINE 49 - (WKST D PART III COLUMN 8 LINE 31 + WKST D PART IV COL 7 LINE 101))
2. TOTAL MEDICARE CHARGES 1217026 (WKST D-4 LINE 31 COLUMN 2 PLUS WKST D-4 LINE 103 COLUMN 2) (SEE CR 5619)
3. RATIO OF COST TO CHARGES (LINE 1 / LINE 2) .634
II. COST TO CHARGE RATIO FOR CAPITAL
1. TOTAL MEDICARE INPATIENT PPS CAPITAL RELATED COSTS 4389222 (WKST D PART I LINES 25-30, COLS 10 & 12 + WKST D PART II, LINE 101, COLS 6 & 8)
2. RATIO OF COST TO CHARGES (LINE II-1 / LINE I-2) .025
III. COST TO CHARGE RATIO FOR OUTPATIENT SERVICES
1. TOTAL PROGRAM (TITLE XVIII) OUTPATIENT COST 16114939 EXCLUDING SERVICES NOT SUBJECT TO OPPS. (WKST D, PART V, COLUMNS 2, 2.01, 3, 3.01, 4, 4.01, 5, 5.01, 5.03 & 5.04 x (WKST B, PART I, COLUMN 27 - COLUMNS 21 & 24 / WKST C, PART I, COLUMN 8) LESS LINES 45, 50 - 52, 57, 64, 65 & SUBSCRIPTS, & 66) (SEE CR 5238))
2. TOTAL PROGRAM (TITLE XVIII) OUTPATIENT CHARGES 61743195 EXCLUDING SERVICES NOT SUBJECT TO OPPS. (WKST D, PART V, LINE 104, COLUMNS 2, 2.01, 3, 3.01, 4, 4.01, 5, 5.01, 5.03 & 5.04 LESS LINES 45, 50 - 52, 57, 64, 65 & SUBSCRIPTS, & 66)
3. RATIO OF COST TO CHARGES (LINE 1 / LINE 2) .261